Every finding on record at Millbrook Healthcare and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to provide a private meeting space for residents' monthly Resident Council Meeting for 10 of 10 confidential residents reviewed for Resident Council.The facility failed to provide a private space for residents who attended monthly Resident Council Meetings.This failure could place residents at risk of not being able to voice their concerns amongst each other due to a lack of privacy.Findings included:During an interview on 04/20/26 at 10:46 a.m., the Activities Director stated the confidential group meeting on 04/21/26 with the residents of Resident Council and the State Surveyor would be held at 2:00 p.m. in the facility's Activities Room located at the end of the 200 Hall. The Activities Director stated since her employment at the facility, the residents monthly Resident Council Meetings were held in the Activities Room.During an observation on 04/20/26 at 1:38 p.m. of the Activities Room at the end of 200 Hall revealed the space was an open area and did not include any door (s) that separated the area from the 200 Hall for privacy. The Activities Room was adjacent to the 200 Hall, which included 15 resident rooms. The Activities Room area shared common walls with two occupied resident rooms on the 200 Hall. The Activities Room had one interior/exterior side door that led to the facility's designated Smoking Area for the residents in the facility who were smokers. During the observation, several residents and staff members were observed entering and exiting the interior/exterior side door of the Activities Room. Observation revealed a partition barrier with a grey curtain on wheels.During an interview on 04/20/26 at 10:46 a.m., the Activities Director stated she was employed for three months. She stated during the monthly Resident Council Meetings, she would place the partition barrier with a grey curtain on wheels between the 200 Hall and the Activities Room. She stated that the partition barrier with a grey curtain on wheels had a sign that stated, Resident Council Meeting in Progress. She stated the monthly Resident Council Meetings were held in the Activities Room, but no staff members or residents had entered the Activities Room via the 200 Hall because of the posted sign on the partition barrier. She stated no staff members or residents had entered the Activities Room via the interior/exterior side door and interrupted the monthly Resident Council Meetings. She stated that she would have to think about a place to have the monthly Resident Council Meetings and suggested the Employee Break Room. She stated that the Employee Break Room would not work because the Employee Time Clock for Employees was in there. The Activities Director stated there was a risk for residents not to have privacy when there was not a door in the area where the monthly Resident Council Meetings were held. She stated without any doors in the area where the monthly Resident Council Meetings, there was potential for the discussions to be overheard by staff, residents or anyone on the 200 Hall. The Activities Director stated that if the discussions in the monthly Resident Council Meetings were overheard by someone, it could cause harm such as retaliation to a resident because what they discussed was not confidential.During an interview on 04/20/26 at 11:27 a.m., the Activities Director stated the confidential group meeting on 04/21/26 with the residents of Resident Council and the State Surveyor would be held in the Private Dining Room on the 100 Hall for privacy.A confidential group meeting was held at an undisclosed date and time in the Private Dining room [ROOM NUMBER] Hall. In the confidential group meeting, 10 residents that regularly attended the facility's monthly Resident Council Meetings stated that their monthly Resident Meetings were held in the Activities Room, which was adjacent to the 200 Hall. The residents described the Activities Room area as being a room connected to the 200 Hall. The residents stated that the Activities Room had one interior/exterior side door that led to the facility's designated Smoking Area and parking lot. The residents stated the large opening that led to the 200 Hall did not provide any privacy for the residents to discuss what they needed to discuss about the facility operations, including their concerns regarding the staff and the care they received by the staff and there was no privacy. The residents stated they had never had any Resident Council Meetings in the area where the Resident Council Meeting was being held on 04/21/26. The residents stated during some of their previous monthly Resident Council Meetings, they were disrupted by staff during their meetings and would prefer that staff and residents did not enter the Activities Room during their meetings, which occurred on several occasions. The residents stated they would prefer to have their monthly Resident Council Meetings in a location that had doors to ensure privacy and would not allow staff or residents to overhear what was being discussed in their meetings to prevent retaliation from staff and other residents. The residents stated the Private Dining Room provided privacy and would prefer to have their monthly Resident Council Meetings in the same area where the confidential group was held on 04/21/26.During an interview on 04/21/26 at 2:56 p.m., CNA A revealed she was employed at the facility for one year. CNA A stated she was unaware the facility needed to have a private area that allowed residents who attended the monthly Resident Council Meetings with privacy, which included doors to ensure privacy for the residents during their meetings. CNA A stated that residents had not told her anything about wanting to have more privacy during the monthly Resident Council Meetings. CNA A stated that the monthly Resident Council Meetings were held when she was not on duty. CNA A stated the risk of not having a secure area for the residents during their monthly Resident Council was the residents did not have privacy due to there not being doors between the 200 Hall. She stated residents may not feel comfortable expressing themselves during their monthly Resident Council Meetings if what they discussed was overheard by anyone who was not attending the meetings. She stated the doors would provide privacy and some protection for the residents to have discussions amongst themselves. She stated the members of the Resident Council have the right to have privacy during their monthly Resident Council Meetings. CNA A stated if a resident(s) mentioned their concerns during one of their monthly Resident Council Meetings and the discussions were overheard and involved another resident or staff member, there was a potential for harm to the residents in the meeting to face being retaliated against and may cause arguing and disagreements with the person that overheard what was being discussed in the meetings.During an interview on 04/21/26 at 3:17 p.m., CNA B revealed she was employed for one year. CNA B stated she was unaware the facility needed to have a private area that allowed residents who attended the monthly Resident Council Meetings with privacy, which included doors to ensure privacy for the residents during their meetings. CNA A stated residents had not told her anything about wanting to have more privacy during the monthly Resident Council Meetings. CNA B stated that there was a risk to residents that attended the monthly Resident Council Meetings to have everything they mentioned in the meeting being overheard by someone who did not attend the meeting. CNA B stated that harm could be caused to a resident, if their discussions were overheard, which could cause retaliation and an unsafe environment for the staff and residents.During an interview on 04/21/26 at 4:05 p.m., the Administrator stated that the facility did not have a policy on Resident Council and Resident Council Meetings.Record review of the facility's undated policy, Notice of Resident Rights and Responsibilities, did not provide any information relating to Resident Council and Resident Council Meetings.Record review of the facility's, List of Smokers reflected there were 8 residents in the facility who were Smokers.

Based on interview and record review the facility failed to develop a person-centered, comprehensive care plan for each resident that included measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs for 6 (Resident #12, Resident #9, Resident #43, Resident #4, Resident #59, Resident #8) of 6 residents reviewed for care plans.1 The facility failed to revise the person-centered care plan for six (Resident #12, Resident #9, Resident #43, Resident #4, Resident #59, Resident #8) of six residents addressed their interventions for Full Code or DNR on their Advanced Directives. 2. The facility failed to include the Advanced Directives for one (Resident #8) of one resident on the resident's Care Plan.These failures could affect residents at the facility by placing them at risk of not receiving the appropriate services, care and treatments needed to maintain their optimal health.Findings included:Record review of Resident #12's admission face sheet dated 04/22/26 reflected he was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with active diagnoses that included: encephalopathy (any disease, damage, or malfunction of the brain that causes an altered mental state, such as confusion, memory loss, or reduced consciousness0, dementia (memory loss), schizoaffective disorder and multiple sclerosis (a chronic disease of the central nervous system (brain, spinal cord, and optic nerves), and acute kidney failure. Resident #12's Advance Directive was listed as DNR-DO NOT RESUSCITATE.Record review of Resident #12's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 3 indicated severe cognitive impairment.Record review of Resident #12's Care Plan printed 04/20/2026 reflected, Focus: Resident has initiated Advanced Directives.Date Initiated: 03/13/2025Revision on: 03/13/2025Goal: Advanced Directive preferences will be honored through review date.Date Initiated: 03/13/2025Target Date: 05/13/2026Interventions/Tasks: Provide advanced directive education and support in directive completion.Date Initiated: 03/13/2025 Review advanced directives and preferences quarterly and PRN with resident / RP.Date Initiated: 03/13/2025 Update contact information with Power of Attorney/ Legally Authorized Representative information.Date Initiated: 03/13/2025 Update resident's chart to reflect elected code status, staff must be aware of code status election.Date Initiated: 03/13/2025Record review of Resident #12's Order Summary printed 04/22/26 reflected an active verbal order on 03/29/26 for DNR-DO NOT RESUSCITATE.Record review of Resident #12's OOH DNR was signed by Resident #12 on -1/25/2018.Record review of Resident #43's admission face sheet dated 04/20/26, reflected a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses that included: dementia with anxiety, COPD (chronic pulmonary disease - a progressive, incurable lung disease that obstructs airflow, causing chronic breathing difficulties), chronic bronchitis and Type 2 diabetes. Resident #43's Advance Directive was Full Code (use AED - automated External Defibrillator) with CPR during sudden cardiac arrest.Record review of Resident #43's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 12 indicated moderate cognitive impairment.Record review of Resident #43's Care Plan printed 04/20/2026 reflected, Focus: Resident has been educated about an Advanced Directive.Date Initiated: 02/29/2024Revision on: 11/25/2024Goal:Code Status election will be honored through review dateDate Initiated: 02/29/2024Revision on: 11/17/2025Target Date: 06/19/2026Interventions/Tasks: Provide advanced directive education and support in directive completion.Date Initiated: 11/25/2024 Review advanced directives and preferences quarterly and PRN with resident / RP.Date Initiated: 11/25/2024 Review code status quarterly and PRN with resident / RPDate Initiated: 02/29/2024 Update contact information with Power of Attorney/ Legally Authorized Representative information.Date Initiated: 11/25/2024 Update resident's chart to reflect elected code status, staff must be aware of code status election.Date Initiated: 02/29/2024Record review of Resident #43's Order Summary printed 04/20/26 reflected an active verbal order on 01/08/24 for FULL CODE: USE AED (Automated External Defibrillator) WITH CPR DURING SUDDEN CARDIAC ARREST.Record review of Resident #9's admission face sheet dated 04/23/26 reflected he was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with active diagnoses that included: Type 2 diabetes, stroke, chronic kidney disease and chronic kidney disease. Resident #9's Advance Directive was listed as CPR/Full Code.Record review of Resident #9's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 12 indicated moderate cognitive impairment.Record review of Resident #9's Care Plan printed 04/23/2026 reflected, Focus: Resident has been educated about an Advanced Directive.Date Initiated: 04/09/2024Goal:Code Status election will be honored through review date.Date Initiated: 04/09/2024Revision on: 01/29/2025Target Date: 04/15/2026Interventions/Tasks: Review code status quarterly and PRN with resident / RP.Date Initiated: 04/09/2024 Update resident's chart to reflect elected code status, staff must be aware of code status election.Date Initiated: 04/09/2024Record review of Resident #9's Order Summary printed 04/23/26 reflected an active phone order on 05/09/24 for CPR/FULL CODE.Record review of Resident #4's admission face sheet dated 04/20/26 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses that included: dementia with anxiety, COPD (chronic pulmonary disease - a progressive, incurable lung disease that obstructs airflow, causing chronic breathing difficulties), chronic bronchitis and Type 2 diabetes. Resident #4's Advance Directive was Full Code (use AED - automated External Defibrillator) with CPR during sudden cardiac arrest.Record review of Resident #4's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 12 indicated moderate cognitive impairment.Record review of Resident #4's Care Plan printed 04/20/2025 reflected, Focus: Resident has been educated about an Advanced Directive.Date Initiated: 02/29/2024Revision on: 11/25/2024Goal:Code Status election will be honored through review dateDate Initiated: 02/29/2024Revision on: 11/17/2025Target Date: 06/19/2026Interventions/Tasks: Provide advanced directive education and support in directive completion.Date Initiated: 11/25/2024 Review advanced directives and preferences quarterly and PRN with resident / RP.Date Initiated: 11/25/2024 Review code status quarterly and PRN with resident / RPDate Initiated: 02/29/2024 Update contact information with Power of Attorney/ Legally Authorized Representative information.Date Initiated: 11/25/2024 Update resident's chart to reflect elected code status, staff must be aware of code status election.Date Initiated: 02/29/2024Record review of Resident #4's Order Summary printed 04/20/26 reflected an active verbal order on 01/08/24 for FULL CODE: USE AED (Automated External Defibrillator) WITH CPR DURING SUDDEN CARDIAC ARREST.Record review of Resident #59's admission face sheet dated 04/23/26 reflected she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with active diagnoses that included: anoxic brain damage (brain injury caused by a total lack of oxygen reaching the brain, leading to cell death within minutes), epilepsy (chronic neurological disorder characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical activity in the brain), and quadriplegia (paralysis causing partial or total loss of motor and/or sensory function in all four limbs (arms and legs) and the torso, resulting from a cervical spinal cord injury or brain injury), and anemia in chronic kidney disease. Resident #59's Advance Directive was Full Code (use AED - automated External Defibrillator) with CPR during sudden cardiac arrest.Record review of Resident #59's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 12 indicated moderate cognitive impairment.Record review of Resident #59's Care Plan printed 04/23/2025 reflected, Focus: Resident has been educated about an Advanced Directive.Date Initiated: 05/20/2024Revision on: 11/25/2024Goal: Code Status election will be honored through review date.Date Initiated: 05/20/2024Revision on: 05/21/2025 Advanced Directive preferences will be honored through review date.Date Initiated: 11/25/2024Revision on: 05/21/2025Interventions/Tasks: Provide advanced directive education and support in directive completion.Date Initiated: 05/20/2024 Review advanced directives and preferences quarterly and PRN with resident / RP.Date Initiated: 05/20/2024 Review code status quarterly and PRN with resident / RPDate Initiated: 05/20/2024 Update resident's chart to reflect elected code status, staff must be aware of code status election.Date Initiated: 05/20/2024. Record review of Resident #59's Order Summary printed 04/23/26 reflected an active verbal order on 03/08/25 for FULL CODE: USE AED (Automated External Defibrillator) WITH CPR DURING SUDDEN CARDIAC ARREST. Record review of Resident #8's admission face sheet dated 04/23/26 reflected she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted [DATE] with active diagnoses that included: postprocedural hypothyroidism (an underactive thyroid condition resulting from thyroid removal surgery), schizoaffective disorder ( a chronic mental health condition combining symptoms of schizophrenia (psychosis) and mood disorders (mania or depression), and Type 2 diabetes. Resident #8's Advance Directive was Full Code (use AED - automated External Defibrillator) with CPR during sudden cardiac arrest.Record review of Resident #8's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 13 indicated intact cognition.Record review of Resident #8's Care Plan printed 04/20/2026 reflected, no Advanced Directives.Record review of Resident #8's Care Plan printed 04/23/2026 was updated and reflected, Focus: Resident has elected Full Code statusDate Initiated: 04/22/2026Revision on: 04/22/2026Goal: Advanced Directive preferences will be honored through review date.Date Initiated: 04/22/2026Target Date: 08/04/2026Interventions/Tasks: Initiate full code measures in case of cardiac arrest, to include CPR and AED use.Date Initiated: 04/22/2026 Provide advanced directive education and support in directive completion.Date Initiated: 04/22/2026 Review advanced directives and preferences quarterly and PRN with resident / RP.Date Initiated: 04/22/2026 Review code status quarterly and PRN with resident / RP.Date Initiated: 04/22/2026 Update resident's chart to reflect elected code status, staff must be aware of code status election.Date Initiated: 04/22/2026Record review of Resident #8's Order Summary printed 04/23/26 reflected an active phone order on 01/29/26 for FULL CODE: USE AED (Automated External Defibrillator) WITH CPR DURING SUDDEN CARDIAC ARREST.During an interview with the MDS Coordinator on 04/22/26 at 11:10 AM, she stated that she had been employed at the facility for 1 1/2 years. She stated she recently became the MDS Coordinator at the facility in December 2025. The MDS Coordinator stated she was unaware that the Care Plans for Resident #12, Resident #9, Resident #43, Resident #4, Resident #59, Resident #8 addressed their interventions for Full Code or DNR on their Advanced Directives. The MDS Coordinator stated she was unaware that the Care Plan for Resident #8 did not include the Advanced Directives. The MDS Coordinator stated that the residents Advanced Directives should reflect if they requested Full Code or DNR. She stated that she had been on Leave from work and during her Leave of Absence from work, the facility's MDS Resource was given the role of the MDS Coordinator for the facility. The MDS Coordinator stated that she was responsible for inputting information such as the Advanced Directives with special instructions for Full Code or DNR in each resident's EHR. The MDS Coordinator was asked to verify in the facility's EHR if Resident #12, Resident #9, Resident #43, Resident #4, Resident #59, and Resident #8's Advanced Directives included the special instructions per the resident's request of Full Code or DNR, and she confirmed that all 6 resident's Advanced Directives included their requests of being Full Code or DNR. The MDS Coordinator stated the Advanced Directive should have been included in Resident #8's Care Plan upon her admission to the facility. She stated that according to the MDS Training she had taken, the Advanced Directives should be included on each Care Plan. She stated that she would get with the MDS Resource and resident's Care Plans for the residents in the facility. She stated that the risk to a resident is if there was an Emergency, no know would know if the resident requested Full Code or DNR. She stated that the harm caused by the Advanced Directives not being inputted correctly in a resident's Care Plan was there could be a delay in care and treatment to fit the resident's needs.During an interview with the Social Worker on 04/22/26 at 11:35 AM, she stated that she had been employed at the facility for 3 months. She stated that she was unaware that the Care Plans for 6 residents (Resident #12, Resident #9, Resident #43, Resident #4, Resident #59, Resident #8) did not include the special directions of Full Code and DNR. The Social Worker stated that she was unaware that Resident #8 did not have any Advanced Directives on her Care Plan. She stated that the Care Plans she has seen for residents included Advanced Directives but was unsure if the Advanced Directions included Full Code or DNR. She stated that a resident's Care Plan should include if they requested to be Full Code or DNR during an emergency. The Social Worker stated that the Nursing Staff inputted the Advanced Directive information on the resident's Care Plan. She stated that the risk of a resident Care Plan not including Full Code or DNR status would be if a resident were a Full Code and the staff did not perform CPR, that would be unethical and the resident could not survive and could have survived per their request of being Full Code. She stated that the risk of a resident Care Plan not including DNR and the resident was given CPR in an emergency, that would be unethical and the resident would be resuscitated instead of their request of being DNR. The Social Worker stated that psychological harm could be caused to a resident if their wishes were not respected due to their Care Plans being incorrect.During an interview with the DON on 04/22/26 at 12:24 PM, she stated that she had been employed at the facility for 3 years. She stated that she was unaware that the Care Plans for 6 residents (Resident #12, Resident #9, Resident #43, Resident #4, Resident #59, Resident #8) did not include the special directions of Full Code and DNR. The DON stated that she was unaware that Resident #8 did not have any Advanced Directives on her Care Plan. The DON stated that the Nursing Staff were not responsible for inputting the Advanced Directives information on resident's Care Plans. She stated that the Social Worker was responsible for inputting the Advanced Directives information on resident's Care Plans. The DON stated during an emergency the Nursing Staff review the resident's Order Summary to find out if the resident has a Physician's Order for Full Code or DNR. She stated that the Care Profile for residents stated if the resident was DNR or Full Code. She stated the Face Sheet, Order Summary are the 2 documents sent with the resident if they are sent out of the facility to the hospital. The DON stated that there was no risk or harm caused to residents if their Advanced Directives did not include DNR or Full Code.During an interview with CNA A on 04/23/26 at 2:40 PM, stated she had been employed at the facility for 1 year. She stated that she was unaware that the Care Plan for 6 residents (Resident #12, Resident #9, Resident #43, Resident #4, Resident #59, Resident #8) did not include the special directions of Full Code and DNR. CNA A stated that she was unaware that Resident #8 did not have any Advanced Directives on her Care Plan. CNA A stated each resident's Care Plan should include Advanced Directives with special instructions of Full Code and DNR. She stated that harm could be caused to residents if an emergency incident occurred and there were not any special instructions on the resident's Advanced Directives in their Care Plan that stated Full Code or CPR. She stated that the staff or emergency personnel would not know whether or not to perform CPR on a resident depending on their Physicians Orders.Record review of the facility's undated policy, Advanced Directives and Associated Documentation - Resident Rights, reflected, POLICY:It is the policy of this facility that a resident's choice about advanced directives will be recognized and respected. Further, it is the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advanced directive. The facility recognizes and respects the resident's right to choose their treatment and make decisions about care to be received at the end of their life. It is the policy of this facility to implement the resident decisions and directives that are in compliantcompliance with State and/or Federal Law and the policies of this facility. The resident will not be discriminated against for a decision to implement or not implement Advance Directives. Definitions: Advance care planning: Process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions. Advance directive: A written instruction that relates to the provision of health care when the individual is incapacitated, such as a Living Will, Durable Power of Attorney for Health Care or the Natural Death Act. These documents allow the individual to identify choices related to their medical treatment or designate someone to make treatment choices for them should they lose decision making capacity for themselves Agent: The individual (Attorney-in-fact) designated by a person (Principal) pursuant to a Durable Power of Attorney for Health Care to act on his or her behalf in health matters in the event that the person loses decision-making capacity Conservator: The person appointed by a court with the legal power and duty of taking care of and managing the property and/or personal affairs of another person who is considered incapable of administering his/her own affairs Health care decision-making: Refers to consent, refusal to consent, or withdrawal of consent to health care, treatment, service, or a procedure to maintain, diagnose, or treat a resident' physical or mental condition. Health care decision-making capacity: Refers to possessing the ability (as defined by State law) to make decisions regarding health care and related treatment choice. A person is presumed to have a capacity to make health care decisions unless the attending physician determines that the person is incapacitated or a court rules that the person is incompetent. Life Sustaining Treatment/Procedures: Any medical intervention including artificially administered food and fluids that would prolong the dying process or to artificially prolong life in a permanent vegetative state of irreversible coma. Surrogate Decision maker: - An individual who participates in health care decision making on behalf of an incapacitated person. This individual may be formally appointed (by the Durable Power of Attorney for Health Care or by a court in a conservatorship or guardianship proceeding) or, in the absence of a formal appointment, may be recognized by virtue of a relationship with the person (person's next of kin or close friend)The facility has defined advanced directives to include preferences regarding treatment options; the following list reflects examples of such advance directives (and is intended to be illustrative, not exhaustive): Living Will -A document that specifies a resident's preferences about measures that are used to prolong life when there is a terminal prognosis; Do Not Resuscitate - Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health-care proxy, or representative (sponsor) have directed that no cardiopulmonary resuscitation (CPR) is to be attempted; Do Not Hospitalize - Indicates that the resident is not to be hospitalized , even if he/she has a medical condition that would usually require hospitalization; Organ Donation - Indicates that the resident wishes his/her organs to be available for transplantation upon his/her death; Autopsy Request - indicates that the resident, legal guardian, health-care proxy, or representative (sponsor) has requested an autopsy performed upon the death of the resident.NOTE: The person making the request must still be contacted for permission prior to performance of the procedure. Feeding Restrictions - Indicates that the resident, legal guardian, health-care proxy, or representative (sponsor) does not wish for the resident to be fed by artificial means (e.g., tube, intravenous nutrition, etc.) if he/she is not able to be nourished by oral means; Medication Restrictions - Indicates that the resident, legal guardian, health-care proxy, or representative (sponsor) does not wish for the resident to receive life-sustaining medications (e.g., antibiotics, chemotherapy, etc.); and Other Treatmen1t Restrictions - Indicates that the resident, legal guardian, health-care proxy, or representative (sponsor) does not wish for the resident to receive certain medical treatments. Examples include, but are not limited to, blood transfusions, tracheotomy, respiratory incubation, etc. Procedure:1. Prior to, upon, or immediately after admission, a facility staff member shall:a. Provide the resident/family or responsible agent written information, in a manner easily understood by the resident or resident representative, regarding the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directivesb. Document in the resident health record that, at the time of admission, the resident and/or resident representative have been provided with written information regarding advance directives.c. Inquire whether they have completed an Advance Directive. 2. If the resident is incapacitated at the time of admission and is unable to receive information or indicate whether they have executed an advance directive, the facility may give advance directive information to the resident's representative in accordance with existing State law.a. Identify the primary decision-maker.b. If the resident becomes able to receive information at a later point during their admission, the facility will follow its policy relative to the provision of advance directive information to extent permitted by the resident's condition.c. Information will be provided directly to the residents by a member of the care team, in a timely manner.3. When an Advance Directive is not completed, refer the resident/resident representative or decision-maker to their physician to define or clarify medical issues or respond to questions regarding medical or surgical treatment(s).4. If the resident is incapacitated and not capable of independent decision-making at the time of admission: a. Inform the surrogate decision maker to document their desire to initiate an advance directive and their knowledge that this decision is in the resident's best interest or is to comply with resident's known desires, when this need arises.b. If the surrogate decision-maker is a family member, not identified on an Advanced Directive document, all members of the immediate family with equal relationship to the resident will need to agree and sign the document.i. In the event opinions differ among family members, the Advance Directives will not be implemented until a resolution is achieved.c. If there is no surrogate decision maker who can act on behalf of an incapacitated resident, an Advance Directive order may be issued when the attending physician determines it is medically appropriate and concurrence is evident in the resident health record by the Interdisciplinary Team.5. When an Advance Directive is completed:a. Review the Advance Directive to validate the document reflects the resident choices and that the document is signed and dated by the resident or responsible agent.b. If an Advance Directive was completed prior to admission and at the time of admission the resident is no longer capable of independent decision-making, the Advance Directive will be accepted.c. If an Advance Directive was developed in another State or conflicts with the written policies of this facility, the resident/family or responsible agent must be informed at the time of admission.ii. The facility will honor such advance directive documents to the extent permitted by law.iii. If State law prevents the facility from recognizing the foreign advance directive, it will inform the resident or their representative so that action can be taken to recognize the resident's treatment and end-of-life wishes.iv. The resident/family may opt to move to another facility.d. Obtain copy of the Advance Directive and conservatorship/guardianship documents and place in the resident health record.6. Obtain copy of the Advance Directive and conservatorship/guardianship documents and place in the resident health record.a. It should be noted that a Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form is not an advance directive.b. Once the advance directive or information regarding resident preferences regarding treatment options is received by the facility, it will be confirmed in the resident medical record and communicated to members of the care plan team.c. The facility will also notify the attending physician of advance directives so that, if necessary, appropriate orders can be documented in the resident's medical record and plan of care.i. A No CPR or DNR telephone order may be used once Advance Directive documents are received and in the health record.ii. Transfer records shall include copies of the Advance Directives and signed No CPR orders7. Advance care planning will occur periodically (at least quarterly, annually, and on a change of condition) to review the advance directive and/or preferences regarding treatment options with the resident or their representative to ensure that they are still the wishes of the resident. Such reviews will be made during the assessment process and recorded in the medical record.8. The resident or surrogate decision-maker may modify or cancel the Advance Directive decision at anytime.a. Changes or revocations of a directive must be submitted to the facility, in writing.b. The facility may require that the resident or resident representative create/execute new documents if changes are extensive.c. The care plan team, including the physician, will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment instrument (MDS), care plan, or elsewhere in the clinical record.d. Immediate action must be taken to implement desired changes.9. Inquiries concerning advance directives should be referred to social services, and/or to the Director of Nursing Services. Record review of facility's policy, Care Planning, revised April 2006 reflected, POLICY:It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each residentPROCEDURES:1.A comprehensive care plan is developed within seven (14) days of completion of the Resident Minimum Data Set (MDS)2.The care plan is developed by the IDT which includes, but is not limited to the following professionals:A. Attending PhysicianB. Registered Nurse responsible for the residentC.Dietary Supervisor/DietitianD. Social Services staff member responsible for the residentE. Activity staff member responsible for the residentF. Rehabilitation Specialist physical, occupational, and/or speech therapists as indicatedG. Director of Nursing Services (as applicable)H. Nursing assistants responsible for resident careI. Others as necessary or indicated3. To the extent possible, the resident, the resident's family and/or responsible party should participate in the development of the care plan.4. Every effort will be made to schedule care plan meetings to accommodate the availability of the resident and family or responsible party5. When the resident has no family or responsible party, and is unable to make his/her own health care decisions, the IDT will act as surrogate decision makers6. Scheduling and preparation of the care plan meeting calendar is completed by the MDS Coordinator7. The MDS Coordinator, Social Services or designee staff will notify the resident, family and/or responsible party, and other interested parties designated by the resident, of the date and time of the care plan conference prior to the meeting.8.Initial care plan/ Interim care plan - initial care plan is started within 24-hours of admission to provide an overview of the resident's care needs. Initial plan of care can be started in PCC /POC and/or through the use of resident care guidelines, shift to shift report.9.The resident's plan of care - focus, goals, and interventions - are communicated and implemented by the members of the health care continuum accordingly.10.The resident's plan of care is reviewed and revised on an ongoing basis, quarterly at a minimum and/or as needed with changes in condition.Findings included:Record review of Resident #12's admission face sheet dated 04/22/26 reflected he was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with active diagnoses that included: encephalopathy (any disease, damage, or malfunction of the brain that causes an altered mental state, such as confusion, memory loss, or reduced consciousness0, dementia (memory loss), schizoaffective disorder and multiple sclerosis (a chronic disease of the central nervous system (brain, spinal cord, and optic nerves), and acute kidney failure. Resident #12's Advance Directive was listed as DNR-DO NOT RESUSCITATE.Record review of Resident #12's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 3 indicated severe cognitive impairment.Record review of Resident #12's Care Plan printed 04/20/2026 reflected, Focus: Resident has initiated Advanced Directives.Date Initiated: 03/13/2025Revision on: 03/13/2025Goal: Advanced Directive preferences will be honored through review date.Date Initiated: 03/13/2025Target Date: 05/13/2026Interventions/Tasks: Provide advanced directive education and support in directive completion.Date Initiated: 03/13/2025 Review advanced directives and preferences quarterly and PRN with resident / RP.Date Initiated: 03/13/2025 Update contact information with Power of Attorney/ Legally Authorized Representative information.Date Initiated: 03/13/2025 Update resident's chart to reflect elected code status, staff must be aware of code status election.Date Initiated: 03/13/2025Record review of Resident #12's Order Summary printed 04/22/26 reflected an active verbal order on 03/29/26 for DNR-DO NOT RESUSCITATE.Record review of Resident #12's OOH DNR was signed by Resident #12 on -1/25/2018.Record review of Resident #43's admission face sheet dated 04/20/26, reflected a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses that included: dementia with anxiety, COPD (chronic pulmonary disease - a progressive, incurable lung disease [TRUNCATED]

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety.1. The facility failed to ensure food in the facility's dry storage and freezer areas were labeled and dated according to guidelines.2. The facility failed to seal open items in plastic bags in the dry storage pantry, refrigerator, and freezer areas.3. The facility failed to ensure that expired items in the dry storage pantry and freezer areas were removed.4. The facility failed to ensure that dented cans were removed in the dry pantry area and were separated from the other canned food.These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other food-borne illnesses.Findings Included:An Observation of the kitchen during the brief initial tour of the kitchen on 04/20/26 at 5:06 AM, revealed the following:Dry Pantry area:* 1 box of 6 variety packages of Nutritional Powder Drink Mix with an expiration date of 06/18/24.* 4 boxes of 32 oz. powdered cane sugar with an expiration date of 02/16/25.* 1 box of 6 buttermilk pancake mix with an expiration date of 03/06/25.* 1 box of 11 cans of 14.5 oz. diced sweet red peppers with an expiration date of 11/04/25.* 2 bottles of Nepro with Carb Steady Therapeutic Nutrition Drink with an expiration date of 04/01/26.* 1 bottle of Thick and Easy Thickened Dairy Beverage with an expiration date of 02/04/26.* 1 box of 4 bottles of 8 fl. oz. Glucose Control with an expiration date of 10/27/25.* 1 box of 5 lb. buttermilk pancake mix was labeled 4-3 and did not include the year of expiration.* 1 box of 6 lb. chocolate cake mix was labeled 4-3 and did not include the year of expiration.* 1 box of 2 packages of elbow macaroni were labeled 4-3 and did not include the year of expiration.* 1 box of 6 lb. packages of yellow cake mix were not labeled with an expiration date,* 1 container of 80 fl. oz. hamburger pickles were not labeled with an expiration date.* 1 gallon container of sweet n sour sauce was undated and was unsealed and exposed to air.* 1 package of tortillas was undated and was unsealed and exposed to air.* 1 box of 5 lb. boxes of 16 oz. baking soda was unsealed and exposed to air.* 1 bag of 10 lb. enriched macaroni was in a zip loc bag and was unsealed and exposed to air.* 1 bag of 16 oz. Potato Chips were in a plastic Ziploc bag and were unsealed and exposed to air.* 1 package of 22.97 oz. refried pinto beans were in a plastic Ziploc bag and were unsealed and exposed to air.* 2 boxes of 36 oz. grain and wild rice were unsealed and exposed to air.* 1 clear plastic container of labeled, corn meal was unsealed and exposed to air.* 1 package of elbow macaroni was unsealed and exposed to air.* 1 plastic container of labeled sugar was unsealed and exposed to air.* 3 dented cans of 5 oz. Chunk Light Tuna.* 1 box of 5 dented cans of 4 lb. 62 oz. Light Tuna.* 2 dented cans of 14 oz. jellied cranberry sauce.* 1 dented can of 22.6 oz. Cream of Mushroom Soup.* 1 dented can of 62 oz. mushroom pieces and stems.* 1 dented can of 6 lb. 14 oz. black beans.Refrigerator area:* 1 metal pan with 8 bowls of custard in white bowls were unsealed and exposed to air.* 1 metal pan with 1 custard in a clear bowl was unsealed and exposed to air.Freezer area:* 1 plastic Ziploc bag labeled, turkey was unsealed and exposed to air.* 1 metal pan labeled, Hamburger was unsealed and exposed to air. There was a pool of liquified blood observed inside of the metal pan.* 1 white plastic container labeled, margarine was empty and had black particles at the bottom and was filled with water.* 1 white plastic container labeled, shredded cheese had 2 packages of shredded cheese that were unsealed and exposed to air.* 1 white plastic container labeled, shredded cheese had an empty plastic Ziploc bag and there were 10 lunch meat slices located on top of the Ziploc bag which were unsealed and exposed to air.* 1 clear container labeled, gravy was unsealed and exposed to air.* 1 plastic Ziploc bag labeled, turkey included 12 pieces of meat and the meat was white in appearance with green spots.* 1 black plastic bag of bacon was unsealed in an unsealed box and exposed to air.* 1 box of Classic Corndogs were unsealed in an unsealed box and exposed to air.* 1 box of pancakes were unsealed in an unsealed box and exposed to air.* 1 box of beef patties were unsealed in an unsealed box and exposed to air.* 1 plastic bag of 20 taquitos were unsealed and exposed to air.* 1 blue plastic bag of burritos were not labeled with an expiration date.During an interview with the Dietary Manager on 04/20/2026 at 6:14 AM, she stated that she had been employed at the facility for 3 weeks. The Dietary Manager stated that she had a total of 6 staff members in the kitchen, which included 2 staff members per shift. The Dietary Manager was informed about the state surveyors findings during the initial brief tour of the kitchen, which included dented cans, labeling, expired and unsealed items in the dry storage, refrigerator, and freezer areas. She stated that the items that were found by the state surveyor were overlooked by mistake by all kitchen staff. She stated that she performed weekly checks in the dry storage, refrigerator, and freezer areas in the facility's kitchen. She stated that the items that were found by the State Surveyor were not found by her staff and herself during their weekly inspections. She stated every week she would perform a brief tour of the kitchen's dry storage, refrigerator, and freezer areas. She stated that all staff in the facility's kitchen were responsible for ensuring that the items in the dry storage, refrigerator, and freezer areas in the kitchen are labeled, including the name of the item, the date the item was stored and the use by date. She stated that all items in the dry storage, refrigerator, and freezer areas in the kitchen should be sealed and closed and expired items, if found should be immediately thrown away into a trashcan. The Dietary Manager stated all staff are scheduled to ensure items in the kitchen's dry pantry, refrigerator, and freezer areas are not expired, unsealed, including dented cans should be thrown away immediately. She stated she would perform an audit of everything in the kitchen to ensure there were not any unopened and expired items in the dry pantry, refrigerator and freezer areas and the dented cans were removed. She stated her expectation was for staff to throw away any items that are expired or opened in the kitchen's dry pantry, refrigerator and freezer areas and notify her of what they found. She stated that if staff found dented cans, the dented cans were to be immediately removed from the shelf and placed in the designated area for Dented Cans, which was located in her Office. She stated staff have received several in-services relating to food preparation, storage, and labeling and to immediately remove any expired items and the removal of dented cans. The Dietary Manager stated all kitchen staff have been reeducated and retrained on Food Storage, Food Safety and Food Preparation via in-service training. She stated that the staff also have been reeducated on using the First In, First Out (an asset management and valuation method where the oldest inventory, stock, or data items are processed, sold, or used first) procedures to ensure there were not any expired food items throughout the dry pantry, refrigerator, and freezer areas facility's kitchen. The Dietary Manager stated that she would inform all kitchen staff of the findings of the state surveyor's initial brief tour of the kitchen and provide In-Service Trainings on food storage, labeling and ensuring that dented cans were removed from the shelf and placed in the designated area for dented cans. She stated that the In-Service Training will include reeducation on removing expired items from the shelf and utilizing the FIFO method. She stated if staff were to find any food items such as expired items, her expectation was they immediately throw away the item (s) and inform her about the item (s) that were thrown away. She stated if any item (s) were not labeled and/or dated, her expectation was for her staff to inform him of their findings, therefore she would reeducate and retrain all kitchen staff through in-service training. She stated all kitchen staff were to ensure items in the kitchen's dry pantry, refrigerator, and freezer areas were not expired, unsealed, labeled, dated, and dented cans should be removed. She stated the kitchen staff were reeducated and retrained through in-service training regularly, which was monthly or as needed. She stated that she could not recall when the kitchen staff received their previous in-service training on Food Storage was taken. She stated if anyone ate food from the kitchen that was expired, dented cans and unsealed containers or bags, there was risk of becoming very ill, which could cause them to have stomach issues including stomach aches, vomiting and diarrhea due to cross-contamination and food-borne illness.During an interview with Dietary Aide I on 04/21/26 at 11:48 AM, she stated that she had been employed at the facility for 7 months. She stated that she was unaware there were expired and unsealed items in the dry storage, and refrigerator areas on 04/20/26. Dietary Aide I stated she was unaware that dented cans were observed in the facility's dry storage area on 04/20/26. Dietary Aide I stated that the Dietary Manager informed the kitchen staff about the state surveyors findings during the initial brief tour of the kitchen on 04/20/26. She stated all the staff were responsible for labeling and storing the items on the shelf and checking the expiration dates on everything in the dry storage, refrigerator, and freezer areas in the facility's kitchen. Dietary Aide I stated dented cans were to be immediately removed from the shelf with the other dented cans and placed in the designated area marked Dented Cans, which was in the Dietary Managers Office. Dietary Aide I stated that all kitchen staff received previous education and training on food storage utilizing the FIFO method. Dietary Aide I stated if she observed food that was expired and/or unsealed, and not labeled in the dry pantry, refrigerator, and/or freezer areas, she would immediately trash the item(s), then immediately notify the Dietary Manager of her findings. Dietary Aide I stated that prior to 04/20/26, the Dietary Manager provided several In-Service training courses for all kitchen staff on food storage, handling, and preparation. She stated all the staff were responsible for labeling and storing the items on the shelf and checking the expiration dates on everything in the dry storage, refrigerator, and freezer areas in the facility's kitchen. Dietary Aide I stated dented cans were to be immediately removed from the shelf with the other dented cans and placed in the designated area marked Dented Cans. Dietary Aide I stated that all kitchen staff received previous education and training on food storage utilizing the FIFO method. She stated if she observed any food item (s) that was expired and/or unsealed, and not labeled in the facility's dry pantry, refrigerator, and/or freezer, she would immediately trash the item (s), then immediately notify the Dietary Manager of her findings. Dietary Aide I stated if someone ingested food from the facility's kitchen dry pantry, refrigerator and freezer areas that were unsealed or expired, or from dented cans they were at risk of food-borne illness from cross-contamination and could become sick. She stated that any ingestion of food that had been unsealed or expired, or from dented cans can cause a person to have stomach issues including stomach aches, diarrhea and vomiting.During an interview with Dietary Aide J on 04/21/26 at 12:05 PM, she stated that she had been employed at the facility for 2 years. She stated that she was unaware that there were expired and unsealed items in the dry storage, refrigerator, and freezer areas on 04/20/26. Dietary Aide J stated she was unaware that dented cans were observed in the facility's dry storage area on 04/20/26. Dietary Aide J stated that the Dietary Manager informed the kitchen staff about the state surveyors findings during the initial brief tour of the kitchen on 04/20/26. She stated that all the staff were responsible for storing the items on the shelf and checking the expiration dates on everything in the kitchen. She stated that she had taken in-service trainings on food preparation and storage and her last in-service training was about a few weeks ago. She stated prior to 04/20/26, all kitchen staff were In-Serviced by the Dietary Manager to use the First In, First Out Method, which meant that kitchen staff should label the food with the dates they store them, and when staff are restocking the shelves, they are to put the older foods in front or on top so they can be used first. She stated that if a staff member in the kitchen sees any item(s) that are expired, the staff member was to immediately throw the item away in the trash and notify the Dietary Manager what item(s) were thrown away. She stated that everything in the dry storage, freezer and refrigerator should be labeled and dated. Dietary Aide J stated that dented cans should not be placed on the shelves with the other dented cans and need to be immediately removed from the shelf if found and placed in the designated area labeled Dented Cans in the Dietary Managers office and notify the Dietary Manager. She stated that She stated that all staff were responsible for ensuring that the food items in the facility's kitchen were sealed and not exposed to air including the dry storage, refrigerator and freezer areas. Dietary Aide J stated that if food item(s) were found to be unsealed and exposed to air, she would immediately throw the item away and notify the Dietary Manager. She stated if someone ingested any food item(s) that had been cross-contaminated, there was a risk that someone could have severe stomach issues and diarrhea. She stated that with food in the dry pantry, refrigerator and freezer areas being unsealed and expired items or from dented cans can cause anyone who ingests the food to have an airborne illness and become sick which can cause them harm.Record review of facility's policy, Infection Control - Dietary Services, revised 05/2007 reflected, POLICY:It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness.PROCEDURES:1.Director of Food Service ResponsibilitiesA. Provide safe food services for residents and employees.3. Personnel.B. Education1. Basic orientation and annual in-service education will include.food handling sanitation.5.Food StorageA. Upon arrival, all food will be inspected for damage.G. Old stock is rotated and used first.6. Proper Food Handling.B. Foods coming from broken packages or swollen cans or food with abnormal appearance or odor will not be served.K. Leftovers must be dated, labeled, covered and stored.in a refrigerator, not at room temperature.8. Dietary Housekeeping.G. Storage facilities for raw and cooked food must be cleaned and sanitized on a fixed schedule.Record review of the facility's undated policy titled, Food Storage reflected, POLICY:It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner.PROCEDURES:1.Food storage areas shall be clean at all times.2.The dietary manager, or his/her designee, will check refrigerators and freezers at least daily.Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #65 and #89) reviewed for infection control. The facility failed to ensure CNA C wore appropriate PPE and completed hand hygiene while providing incontinent care to Resident #65.The facility failed to ensure CNA E wore the appropriate PPE while transferring and providing incontinent care to Resident #89.The facility failed to ensure CNA F wore the appropriate PPE and completed hand hygiene while transferring and providing incontinent care to Resident #89.The facility failed to ensure that hand hygiene was completed by staff when providing care to Resident #89, who was on enhanced barrier precautions per facility policy, and that LVN H, the infection control preventionist understood the facility's policy on hand hygiene. This failure could place residents at risk of being infected by staff in contact with other residents with infections.Findings included:Review of Resident 65's Quarterly MDS assessment dated [DATE] revealed a [AGE] year-old male, admitted to the facility 05/06/25. Admitting diagnoses included hypertension (high blood pressure), muscle weakness, muscle waiting (thinning of muscles), lack of coordination, gastrostomy status (individual has a surgically placed gastrostomy tube (medical device inserted through the abdominal wall directly into the stomach to provide nutrition, fluids, and medication) and cognitive communication deficit. Resident #65 was always incontinent with bowels and bladder and required maximum assistance with toileting. Review of Resident #65's care plan revised on 08/28/26 reflected, Resident #65 had bowel and bladder incontinence related to dementia, and impaired mobility. Goal, will remain free from skin breakdown and intervention, check as required for incontinence. Observation on 04/20/2026 at 5:25 AM, revealed CNA C providing incontinent care to Resident #65. CNA C completed hand hygiene and double gloved and did not put on a gown. CNA C cleaned the resident, the resident had a moderate amount of bowel movement. Without changing gloves or any form of hand hygiene, CNA C proceeded and applied the clean brief and then she took off a pair of gloves and remained with one pair. CNA C then positioned Resident #65 and turned on the feeding pump. The posting on the door indicated the staff were required to put on a gown and gloves while taking care of the resident. In an interview on 04/20/2026 at 6:08 AM, CNA C stated she had not been informed to use the gown while taking care of residents with a G-tube. CNA C stated she had taken care of other residents who had a G-tube and she did not wear a gown. CNA C stated according to her training after being hired she was not supposed to clean her hands in-between care, and she was only expected to clean her hands before and after care. CNA C stated she had been educated on infection control upon hire about two weeks ago. CNA C stated infection control was to be maintained to prevent the spread of infection. Review of Resident 89's admission MDS assessment dated [DATE], reflected an [AGE] year-old female, initial admission to the facility on [DATE] and re-admitted on [DATE]. Admitting diagnoses included anorexia (eating disorder), heart failure (inability of the blood to send enough blood), dysphagia (difficult swallowing) and malnutrition (lack of proper nutrition). Resident #89 required moderate assistance with activities of daily living. Review of Resident #89's care plan dated 04/20/26 reflected Resident #89 had nutritional problem related to malnutrition and she had a with G-tube. There was no information in the care plan regarding EBP. Observations on 04/21/2026 at 10:58 AM, revealed CNA E and CNA F assisting Resident # 89 with transfer and incontinent care. The staff gloved but they did not have a gown on. During care CNA F did not complete hand hygiene after cleaning the resident who was soiled with urine and used the same gloves to apply the clean brief. With the same gloves CNA F assisted Resident #89 to get dressed and transferred the resident from the bed to the chair. In an interview on 04/21/2026, at 11:15 AM CNA F stated she was supposed to change gloves and complete hand hygiene after cleaning the resident, but she forgot. She stated regarding PPE use she was not aware she was supposed to put on a gown and gloves, and she had checked with LVN G, and LVN G confirmed with her that she did not require PPE while taking care of Resident #89 because the resident was not in any precaution. CNA C stated she was to maintain infection control to prevent cross contamination and prevent the spread of infections. In an interview on 04/21/2026 at 1:34 PM, CNA E she stated she was in-serviced on infection completed on 04/20/2026 on precautions signs on the door, if there was a posting on the door the staff was to mask and gown up. CNA E stated she did not see the posting until after caring for the resident. CNA E stated Resident #89 had a G-tub, but she had not seen the G-tube being used. CNA E stated she was to maintain infection control to prevent the spread of infections. In an interview on 04/21/2026 at 1:57 PM, LVN G stated she was not aware of the residents who were to be on EBP. She stated staff were to use gowns for the residents who were in isolation but not the ones with the G-tube. LVN G stated Resident #89 had a G-tube and staff did not need to gown when taking care of the resident, the staff were required to put on gloves. LVN G stated she had been in-serviced on infection control about 4 weeks ago. She stated the staff were to maintain infection control to prevent the spread of infection. In an interview on 04/21/26 at 2:05 PM, LVN H (Infection Preventionist) stated the staff in the facility had been in-serviced on infection control. She said staff were expected to wear a gown and gloves while taking care of residents who were on EBP. She said it was posted on the door for the residents who EBP and reminded the staff what to wear. LVN H stated both CNA's and LVN's were to wear gowns and gloves when taking care of residents who were on EBP. LVN H stated if staff completed incontinent care, and the resident was soiled with urine, staff were not required to complete hand hygiene after changing gloves. LVN H said staff were to change gloves up to three times when providing care to the residents and then complete hand hygiene. LVN H stated when completing wound care, she was not required to complete hand hygiene after changing gloves three times, after the third time then she would complete hand hygiene. LVN H stated she was not aware what the infection control policy indicated regarding hand hygiene. LVN H stated staff were to maintain infection control to prevent the spread of infection and cross contamination. In an interview on 04/22/2026 at 10:27 AM, the DON stated residents who had any skin openings were placed on EBP and staff were expected to wear a gown and gloves while taking care of those residents. She said each resident on EBP had a posting on the door and PPE in the room. She said regarding hand hygiene, staff were to complete hand hygiene every time they changed gloves. She said staff were to complete hand hygiene after cleaning the resident, before applying clean brief or touching any of the residents' belongings. The DON stated the staff were to maintain infection control to prevent cross contamination and spread of infection. The DON stated nursing staff had been in-serviced on infection control. Review of the facility policy revised 04/12 and titled Hand Washing reflected, It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff.Review of the facility policy revised 10.22 and titled Infection Prevention and Control Program reflected, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program Facility did not provide a policy on EBP on request and by exit.

Based on observation, interview, and record review, the facility failed to provide maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable Dining Room for 10 of 10 confidential residents reviewed for safe, clean, and homelike environment.1.The facility failed to ensure the one chandelier in the Dining Room was clean and not dusty on 04/20/26, 04/21/26, and 04/22/26.2.The facility failed to ensure the one chandelier in the Dining Room had an operating bulb on 04/20/26, 04/21/26, and 04/22/26.3.The facility failed to ensure the four ceiling fans in the Dining Room were clean and not dusty on 04/20/26, 04/21/26, and 04/22/26.4.The facility failed to ensure that seven lights in the Dining Room were working properly on 04/20/26, 04/21/26, and 04/22/26.These failures place residents at risk for a diminished quality of life, poor vision, and clean homelike environment.Findings included:During an observation of the facility's Dining Room on 04/20/26 at 6:55 a.m., there were four Ceiling Fans above four tables in the Dining Room that were dusty. The observation revealed that there was one chandelier that was dusty which had one light bulb that was not working properly. The one chandelier was above two tables in the Dining Room. The observation revealed that there were 5 of 20 lightbulbs that were not working. The observation revealed that two lightbulbs were not working properly and were continuously flashing off and on.During an observation of the facility's Dining Room on 04/21/26 at 1:06 p.m., there were four Ceiling Fans above four tables in the Dining Room that were dusty. The observation revealed that there was one chandelier that was dusty which had one light bulb that was not working properly. The one chandelier was above two tables in the Dining Room. The observation revealed that there were 5 of 20 lightbulbs that were not working. The observation revealed that two lightbulbs were not working properly and were continuously flashing off and on.During an observation of the facility's Dining Room on 04/22/26 at 10:32 a.m., there were four Ceiling Fans above four tables in the Dining Room that were dusty. The observation revealed that there was one chandelier that was dusty which had one light bulb that was not working properly. The one chandelier was above two tables in the Dining Room. The observation revealed that there were 5 of 20 lightbulbs that were not working. The observation revealed that two lightbulbs were not working properly and were continuously flashing off and on.A confidential group meeting was held at an undisclosed date and time included ten residents, it was revealed that the lighting in the Dining Room was very dim. The residents stated that they ate their meals in the facility's Dining Room, the residents stated they had not noticed or observed the dust on the chandelier and ceiling fans. The residents stated they would prefer that all the light fixtures in the facility's Dining Room worked properly to prevent further damage to their vision. The residents stated that they would prefer to eat in the facility's Dining Room that included clean light fixtures and fans.During an interview on 04/22/26 at 10:14 AM with the Housekeeping Supervisor, she stated that she had been employed at the facility for three and a half years. She stated that she had six employees, which included three employees that were housekeeping department and three employees that worked in the laundry department. She was informed about the state surveyor's findings during the three days (04/20/23, 04/21/26, and 04/22/26) of observations revealed four of the four ceiling fans were dusty in the facility's Dining Room. The Housekeeping Supervisor was informed that the Dining Observations on three days (04/20/26, 04/21/26, and 04/22/26) revealed that the chandelier in the dining room was dusty and was above two dining room tables and had 1 light bulb that was not working. The Housekeeping Supervisor was informed that the Dining Observations revealed that 5 of the 20 light bulbs in the facility's Dining Room were not working properly and were continuously flashing off and on. The Housekeeping Supervisor stated that during her visits to the facility's Dining Room, she had never looked up and observed that the ceiling fans and chandelier were dusty. She stated that during her previous visits to the facility's Dining Room, she had not noticed that the light bulbs in the chandelier and Dining room were not working properly. She stated that she was always on the go and did not pay attention to the lights and ceiling fans in the facility's Dining Room. She stated that her department was not responsible for ensuring that the lights and ceiling fans were cleaned and working properly. The Housekeeping Supervisor stated that Maintenance Director was responsible for cleaning and dusting the light bulbs, replacing the light bulbs, vents and fans in the facility's Dining Room. She stated that her staff members have never cleaned the ceiling fans and lights in the facility's Dining Room. The Housekeeping Supervisor stated there were risks of dust being on the chandelier and ceiling fans in the facility, included a potential for dust fall on the table, on residents or into a resident's food while sitting at the table eating food. She stated that if someone was diagnosed with asthma and/or dust allergies, there was a risk for further breathing issues to incur. The Housekeeping Supervisor stated that harm could be caused to anyone that ingested dust from the chandelier and ceiling fans in the facility, included further breathing issues, or skin issues, if the dust which could be contaminated with allergens touched the skin. She stated that the risk of the light bulbs not working properly in the Dining Room could affect a person's vision, which could result in poor eyesight. The Housekeeping Supervisor stated that she would reach out to the Maintenance Director and come up with a plan to ensure that the ceiling fans and chandelier were cleaned on a regular basis, and the lights were all operating properly.During an interview on 04/22/26 at 10:38 AM with the Maintenance Director, he stated that he had been employed at the facility for one year. He stated that he was the only employee in the facility's Maintenance Department on 3 days (04/20/23, 04/21/26, and 04/22/26), revealed four of the four ceiling fans were dusty. The Maintenance Director was informed about the state surveyor's findings during the three days (04/20/26. 04/21/26, and 04/22/26) of Observations revealed four of the four ceiling fans were dusty. The Maintenance Director was informed that the Dining Observations on three days (04/20/26, 04/21/26, and 04/22/26) revealed that the chandelier in the dining room was dusty and was above two dining room tables and had one light bulb that was not working. The Maintenance Director was informed that the Dining Observations revealed that 5 of the 20 light bulbs in the facility's Dining Room were not working properly and were continuously flashing off and on. He stated that he was aware of the lighting issues in the facility's Dining Room. He stated that the light fixtures would need to be replaced and he had already ordered the replacement fixtures. He stated that he was not aware that the 4 ceiling fans and chandelier in the facility's Dining Room were dusty. The Maintenance Director stated that he was responsible for cleaning the dust on the light fixtures and the ceiling fans in the facility's Dining Room. He stated that the Housekeeping Department would not be responsible for ensuring the ceiling fans and chandelier were cleaned in the facility's Dining Room because he was the only one who had access to obtaining a ladder to reach the areas. He stated that he would replace the light bulb in the chandelier. He stated that he was not sure when the ceiling fans and chandelier were last cleaned. He stated that he would now ensure he had a cleaning schedule, which included the ceiling fans and light fixtures in the facility's Dining Room. He stated that the cleaning schedule would include checking the light bulbs in all light fixtures in the facility's Dining Room. He stated that he would have an In-Service Training with the staff to ensure that everyone was on the same page. He stated that staff would be advised to notify him via TELS (a software program that provided a specialized building maintenance, asset management, and compliance platform designed for senior living and healthcare facilities) if the lightbulbs and fixtures needed to be replaced, and if the light fixtures and ceiling fans in the facility's kitchen needed to be cleaned. The Maintenance Director stated that the facility did not have any Maintenance Request Logs but used the TELS system for all maintenance-related requests. He stated that the risk of dust being on the ceiling fans and chandelier in the facility's Dining Room was the dust could fall on the table into a resident's food and could be ingested. He stated that if dust is ingested, it could cause infections and food-borne illnesses. He stated that harm could be caused to a person's body if they ingest dust particles such as stomach sickness, breathing issues, and other sicknesses. He stated that the risk of the lighting in the Dining Room being dimmed could cause harm to a resident's vision, included a person being prescribed a new eye glass prescription due to their poor vision.During an interview on 04/23/26 at 2:50 PM with CNA A, she stated that she had been employed at the facility for about one and a half years. She was informed about the state surveyors findings during the 3 days (04/20/26, 04/21/26, and 04/22/26) of Observations revealed four of the four ceiling fans were dusty. CNA A was informed that the Dining Observations on three days (04/20/26, 04/21/26, and 04/22/26) revealed that the chandelier in the dining room was dusty and was above two dining room tables and had one light bulb that was not working. CNA A was informed that the Dining Observations revealed that 5 of the 20 light bulbs in the facility's Dining Room were not working properly and were continuously flashing off and on. CNA A stated that during her visits to the facility's Dining Room, she had not observed the ceiling fans and chandelier were dusty. She stated that during her previous visits to the facility's Dining Room, she had not observed the light bulbs in the chandelier and Dining room were not working properly. CNA A stated if she observed any lights in the facility's Dining Room were not dim and/or not working properly, she would verbally report the issues to the Maintenance Director and/or use the facility's TELS system to report the issue. CNA A stated she would report the dust on the chandelier and ceilings fans verbally to the Maintenance Director and/or use the facility's TELS system to report the issue. CNA stated that dimmed lighting could cause harm to a resident's vision and impaired vision. CNA A stated with impaired vision, there was a potential for someone to hit objects such as walls or another resident. CNA A stated that dust on the facility's ceiling fans and chandelier in the Dining Room could potentially cause harm by the dust particles falling from the fixtures and ceiling fans and possibly causing harm to anyone that has diagnoses of breathing and respiratory issues.Record review of an email from the Administrator on 04/23/2026 at 8:49 AM revealed a receipt for light fixtures that were purchased on 04/22/26 at 7:13 PM.Record review of the facility's policy titled, Accommodation of Needs, dated 08/2023, reflected, POLICY:It is the policy of this facility to assure that a resident has the right to reside and receive services in the facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.DEFINITIONS:Reasonable accommodations of individual needs and preferences means the facility's efforts to individualize the resident's physical environment including: .Facility's common living areasPROCEDURES:1. The facility will evaluate the resident's unique needs and make environmental accommodations to the extent reasonable.3.Furniture and fixtures in common areas should enhance residents' abilities to maintain their independence.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations that involved abuse, neglect, exploitation or mistreatment, that included injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. For 1 of 1 residents (Resident #56) reviewed for adequate supervision.LVN A failed to report an allegation of abuse to the Administrator, when Resident #56 reported that CNA K was a little too rough while providing care, which resulted in the Administrator not reporting the incident to HHSC. The failure could place residents at risk for delayed notification to HHSC and unreported harm.Findings included:During an observation and interview on 04/20/2026 at 9:15 a.m., Resident #56 was lying in bed with a soft cast on Resident #56's left hand. Resident #56 stated CNA K pushed her out of bed, on 04/11/2026, during incontinent care. Resident #56 stated she fell face down while wearing glasses, resulting in blood on the forehead and pain throughout the body. Resident #56 stated she only felt safe when other staff provided care instead of CNA K. The facility initially completed a change of condition, notified the medical director, received new order and sent out to emergency room for further evaluations, guardian was notified, staff were interviewed and provided statements, and in-services were completed.During an interview on 04/21/2026 at 10:00 a.m., while on initial tour, Resident #56 was observed lying in bed. Resident #56 was lying in bed. Resident #56 stated a follow up visit was scheduled for her left hand. During an observation and interview on 04/22/2026 at 9:30 a.m., Resident #56 was lying in bed awake. Resident #56 stated she had no concerns.During an observation on 04/23/2026 at 9:45 a.m., Resident #56 was in bed awake and stated she had no concerns. During an interview with Resident #56 on 04/20/2026 at 9:30 a.m., Resident#56 revealed that on 04/11/2026 during incontinent care CNA K pushed Resident #56 off the bed causing pain throughout Resident #56's body along with caused harm to Resident #56's left hand and forehead resulting in being transported to the emergency room.During an interview with The Administrator on 04/20 at 9:45 p. m. stated Resident #56 had fallen out of bed during incontinent care. The Administrator stated the fall did not warrant a report to HHSC. During an interview on 04/20/2026 at 4:24 p.m., with the Administrator indicated a facility investigations was completed but did not meet the qualifications needed to report to HHSC. The Administrator said Resident #56 never told her CNA K pushed her. The Administrator stated CNA K had wrote a statement and had left for a planned vacation beginning on 4/12/2026 or 04/13/2026 and was expected to return. During an interview on 04/21/2026 at 12:23 p.m., with the DON, stated she was employed for three years. The DON stated Resident #56 had a diagnosis of cerebral palsy and epilepsy. The DON stated Resident #56 changed her stories about events. The DON said Resident #56 was changed from one person assist to a two person assist after the fall. The DON said the therapy department normally assessed the resident at admission to determine if a resident required therapy services. The DON said Resident #56 told her she did not grab the turn bar and kept turning. The DON said if CNA K realized Resident #56 was not far enough up in the bed CNA.K should have asked for assistance. The DON stated CNA K was doing ADL care and when the CNA K turned Resident #56 over, Resident #56 continued to roll off the bed onto the floor. The DON said no one reported the resident was pushed. The DON stated she visited the resident daily after Resident #56 fell. The DON stated In-services on Falls and Abuse Prevention were completed. The DON said the nurse on duty did not report to her at any time that a resident was pushed. The DON stated if the floor nurse was informed of a resident being pushed, regardless of the resident's behavior, a report to HHSC had to be completed. The DON started in-services on Falls and Abuse Prevention were started after HHSC report made. During a telephone interview on 04/22/26 at 11:30 a.m., LVN J stated she was employed since 09/01/2025. LVN J said she did a lot of wound care and worked weekends. LVN J said no allegation of abuse or neglect was reported to her. LVN J stated If she knew of abuse she would send the alleged perpetrator home, ensure CNA K, and residents were safe, and call the Administrator. During an interview on 04/22/2026 at 11:45 a.m., LVN A stated Resident #56 fell out of bed on 04/11/26 during incontinent care with CNA K. LVN A stated she assessed Resident #56 and noted the laceration. LVN A said she sent Resident #56 to the emergency room due to the laceration and pain expressed by the resident. LVN A stated Resident #56 the following day, told her CNA K was rough with her. LVN A said she reported to LVN J that the CNA K, was a little too rough or something to that affect.In an interview on 04/23/2026 at 1:00 p.m., Administrator said she was not sure if it is Care Planned or not but Resident #56 exaggerated and her story changed a lot. The Administrator stated Resident #56 told the Administrator the push was not done with intent.In an interview on 04/24/2026 at 3:30 p.m., the Administrator said she was going to report to HHSC now after the new information. The Administrator said she did not think it was reportable at the time due to the resident. The Administrator stated the injury was considered a fracture and was not a substantial injury. The Administrator stated when there was a fracture that the facility did not know where it came from, it was reportable. During interviews on 04/21/26 at 11:30 a.m., CNA K was unsuccessfully contacted by telephone CNA K was on vacation. CNA K text back stated she boarded an airplane as she was on vacation. Record review of Resident #56's Care Plan, dated 04/21/2026, indicated Cerebral Palsy and Epilepsy. Resident#56's Care Plan reflected a focus for potential of a behavior problem related to yell out with any ADL care provided. Resident exhibits inconsistencies in conversations when talking to her. She embellishes or exaggerates most situations when spoken to or having conversations with Resident#56. Record review of Resident #56's quarterly MDS, dated [DATE], indicated a BIMS of 12 out 15 indicating moderate cognitive impairment.Record review of facility's policy titled Abuse: Prevention of and Prohibition Against, dated, 10/2023, reflected, Policy: It is the policy of this facility to assure that a resident has the right to reside and receive services in the facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.E. Identification1. Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the Facility administrator immediately. 2. Because some cases of abuse are not directly observed, understanding resident outcomes of an abuse can assist in identifying whether abuse is occurring or has occurred. Possible indicators of abuse include but are not limited to: * Bruises, skin tears and injuries of unknown source; * Extensive injuries. * Injuries in an unusual location;H. Reporting/Response1) All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator.

Based on interview and record review, the facility failed to complete a Quarterly MDS Assessment for 1 of 6 residents (Resident #43) reviewed for Resident Assessments.The facility failed to ensure Resident #43's Quarterly MDS Assessment was completed within 90 days and included an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions to ensure that care.This failure could place residents at risk of not having their individual care needs met, which could cause a decline in physical health, psychosocial health, and quality of care.Findings included:Record review of Resident #43's admission face sheet, dated 04/20/26, reflected a [AGE] year-old female, admitted [DATE], with diagnoses that included: dementia (a progressive decline in mental ability-including memory, reasoning, and behavior-severe enough to interfere with daily life), (anxiety (the body's natural response to stress, manifesting as a feeling of fear, dread, or unease about upcoming events or uncertain outcomes), COPD (chronic pulmonary disease - a progressive, incurable lung disease that obstructs airflow, causing chronic breathing difficulties), chronic bronchitis (a form of COPD where your lungs get inflamed and fill with mucus) and Type 2 diabetes (a chronic condition where the body resists the effects of insulin or fails to produce enough to maintain normal blood glucose levels, leading to high blood sugar).Record review of Resident #43's Quarterly MDS Assessment, dated 12/19/25, reflected a BIMS score of 12 indicating moderate cognitive impairment.During an interview with the MDS Coordinator on 04/22/26 at 10:51 AM, she stated that she had been employed at the facility for 1 1/2 years. She stated she recently became the MDS Coordinator at the facility in December 2025. The MDS Coordinator stated she was unaware that the Quarterly MDS Assessment for Resident #43 was last completed on 12/19/25 and needed to be updated. The MDS Coordinator stated that Quarterly MDS Assessments should be completed for every resident every 90 days. She stated that she had been on Leave from work due to her family member being ill and during her Leave of Absence from work, the facility's MDS Resource was given the role of the MDS Coordinator for the facility. The MDS Coordinator stated that she was responsible for opening and closing the Quarterly MDS Assessment for each resident. The MDS Coordinator stated it was her responsibility to open the Quarterly MDS Assessment and inform the rest of the IDT it was open. The MDS Coordinator was asked to verify in the facility's EHR if Resident #43's most recent Quarterly MDS Assessment was completed on 12/19/25, and she stated it was not completed. The MDS Coordinator stated the Quarterly MDS Assessment for Resident #43 should have been completed, and it was on her for not being done within the 90-day timeframe. The MDS Coordinator stated a Quarterly MDS Assessment for Resident #43 was opened on 04/17/26 but was not completed. She stated that she would get with the MDS Resource and audit the MDS Assessments for the residents in the facility. The MDS Coordinator was asked if there was a risk to residents if a Quarterly MDS Assessment was not completed, and she stated that proper care with special instructions would not be followed for each resident's needs.Record review of The In-Service Training Report, dated 04/22/26 revealed, the MDS Resource reeducated the MDS Coordinator via In-Service Training on 04/22/26 for Following the RAI for MDS Completion of Quarterly Assessment.Record review of the Centers for Medicare & Medicaid Services RAI Manual for MDS Quarterly Assessment, dated September 24, 2025, reflected, ARD of Quarterly Assessment must be set within 92 days of the ARD of the previous OBRA Assessment.Federal requirements dictate that a minimum, three quarterly assessments be completed in each 12-month period (if no SCSA or discharge occurs.

Based on observation, interview, and record review, facility failed to ensure residents were protected from accident hazards by not providing adequate supervision, not maintaining a hazard-free environment, resulted in actual or potential harm for 1of 1 residents (Resident#56) reviewed for safe positioning during incontinent care. The facility failed to implement effective safety interventions that would have prevented the resident from falling off the bed, did not provide the level of supervision necessary to prevent avoidable accidents. The facility had 1 of 1 resident who were left in unsafe situations, placing them at risk for falls and injury.These failures could place residents at risk of accidents and injury.Findings Include:Observation at 9:15am on 4/20/26 on initial tour observed Resident #56 in her room lying in the bed, not in a low position as indicated in the care plan.In an interview with Resident #56 on 04/20/26 reflected that on 04/11/26 during incontinent care, the CNA K came in alone to provide her incontinent care. Resident #56 stated that she felt CNA K intentionally pushed her out of the bed resulting in her laceration and broken finger. During an interview on 4/21/2026 at 12:23pm with the DON said Resident #56 told CNA K she did not grab the turn bar and kept turning and rolled off the bed. DON said if the CNA K realized the resident was not far enough up in the bed CNA K should ask for assistance. In an interview on 4/22/2026 at 11:45am with LVN I stated that Resident #56 fell out of bed on 04/11/26 during incontinent care with CNA K. LVN I assessed Resident #56 noted the laceration. LVN I said she sent the resident to the emergency room due to the laceration and pain expressed by the resident. During interviews on 04/21/26 at 11:30 a.m., CNA K was unsuccessfully contacted by telephone. CNA K text back stated she boarded an airplane as she was on vacation. CNA K was on vacation. Record Review of Resident #56's Care Plan dated initiated and revised on 4/21/2026 identified diagnoses of Cerebral Palsy and Epilepsy. Review of Resident #56's MDS assessment dated [DATE] reflected that Resident#56 has a BIMS of 12 indicates a moderate cognitive impairment. Record Review of facility's Incidents By Incident Type report dated 10/20/2025-4/20/26 reflect' s Resident #56 listed in the Fall Incident column indicating a fall on 4/11/26 at 3:42pm.

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #65) of 3 residents reviewed with gastrostomy tubes (G-tubes) medical device inserted through the abdominal wall directly into the stomach to provide nutrition, fluids, and medication.) The facility failed to ensure CNA C did not manage Resident #65's feeding pump by turning the pump on and off during incontinent care. This failure could place residents with G- tubes at risk for complications, aspiration, and pneumonia.Findings included:Review of Resident 65's Quarterly MDS assessment dated [DATE], revealed a [AGE] year-old male admitted to the facility 05/06/25. Admitting diagnoses included hypertension (high blood pressure), muscle weakness, muscle waiting (thinning of muscles), lack of coordination, gastrostomy status (individual has a surgically placed gastrostomy tube (medical device inserted through the abdominal wall directly into the stomach to provide nutrition, fluids, and medication) and cognitive communication deficit. Resident #65 was always incontinent with bowels and bladder and required maximum assistance with toileting. Review of the care plan revised 02/16/26 reflected Resident #65 required tube feeding. Goal, Resident #65 will remain free of side effects or complications related to tube feeding. Interventions, Monitor/document/report to MD PRN: aspiration- fever, SOB, tube dislodged, infection at tube site, self-extubating, tube dysfunction or malfunction, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. In an observation on 04/20/2026 at 5:25 AM, revealed CNA C providing care to Resident #65. Resident #65's was connected to the feeding pump, and the feeding pump was on and the feeding infusing. CNA C was observed pausing the feeding pump before providing care, and when she completed providing care, she turned on the feeding pump. In an interview on 04/20/2026 at 6:08 AM, CNA C stated she normally paused the feeding pump when taking care of residents who had G-tube. She stated she did not inform the charge nurse to stop the feeding pump when providing care to the resident. CNA C stated during her training, the nurses did not pause the feeding pump, and she had not been pausing the feeding pump while proving care. CNA C stated she was a new hire in the facility, and she had not been educated on care with residents with G -tube. CNA C was not aware of any risk from her turning on and off the feeding pump. In an interview on 04/20/2026 at 6:44 AM, RN D she stated the CNA's were not supposed to be pausing or turning off the feeding pump, they were to inform the charge nurse when they were providing care to the residents with the G-tube, and the charge nurse would turn off/pause the feeding. RN D stated CNA C was assigned to Resident #65 who had a G-tube and she had not informed RN D to pause/turn off the feeding pump during care. RN D stated Resident #65 was at risk for aspiration and managing the feeding pump was not within CNA C's scope of practice. In an interview on 04/22/2026 at 10:38 AM, the DON she stated CNA C was not supposed to manage the feeding pump nor was any CNA's allowed to operate the feeding pump. She said the CNA's were expected to inform the charge nurse to turn off/pause the feeding pump during care. The DON stated CNA C had not been educated on taking care of residents with G-tube. The DON stated the CNA's were not to be managing the feeding pumps because of the risk for aspiration and not within the CNA's scope of practice. Review of the facility policy dated 01/2022 and titled, Gastrostomy Tube Care and Management reflected, It is the policy of this facility to provide proper care and maintenance of gastrostomy tubes. The policy did not address who was to manage the feeding pump.

Based on interviews, observations, and record reviews, the facility failed to protect and promote the right to a dignified existence for 1 (Resident#1) out of 3 residents reviewed, The facility failed to provide Resident#1 with a dignified lunch meal service, when the Medical Record Staff stood beside Resident#1 bed and leaned over Resident#1 to feed him on 10/24/25. This failure could result in resident not feeling respected and a decline in Quality of life.Findings included: Record review of Resident#1's face sheet, dated 10/24/25 reflected, he was a [AGE] year-old male who was originally admitted on [DATE] and readmitted on [DATE]. He was diagnosed with but not limited to: Legal blindness as defined in USA (central visual acuity of 20/200 or less in the better eye with the use of a correcting lens, or visual field of 20 degrees or less), Cognitive communication deficit (difficulty in communication caused by problems with underlying cognitive functions like memory, attention, and executive function), Acute Kidney failure (a sudden and significant decline in kidney function that leads to an inability to remove waste products and excess fluid from the body), Unspecified severe protein-calorie malnutrition (a condition characterized by a significant deficiency in both protein and calories, without a specific underlying cause), major depressive disorder (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest), recurrent unspecified, altered mental status unspecified (a change in a person's level of consciousness, orientation, or cognitive function without a specific underlying cause), Type 2 Diabetes Mellitus with ketoacidosis without coma (an acute medical emergency characterized by high blood sugar, ketones in the urine, and an acidic blood state, but the patient remains conscious) and unspecified abnormalities of gait and mobility (any changes or irregularities in the way a person walks or moves that cannot be attributed to a specific underlying medical condition. ). Record review of Resident#1's quarterly MDS assessment, dated 10/20/2025 reflected his BIMS score was 15 which indicated [Resident #1's] cognition was intact. [Resident#1] was independent (Resident completes the activity by themselves with no assistance from a helper) with Eating (The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). Record review of Resident#1's care plan, dated 10/20/2025 reflected: [Resident#1] had renal insufficient r/t AKI. [Resident#1] goal included no s/sx of complications r/t fluid deficit. Resident#1 interventions included assist resident with ADL's and ambulation as needed. Watch for SOB and match level of assistance to residents' current energy level. Resident #1's review reflected, ADL self-care performance deficit r/t blindness. [Resident#1] would maintain level of function.eating [Resident #1] interventions included staff will provide the appropriate level of physical assistance with ADL's as needed due to his self-ability may fluctuate throughout the day. During an observation on 10/24/25 at 12:45 pm, the Medical Records Staff stood next to Resident #1's bed and asked him to take a couple bites of Jello. The Medical Records Staff fed Resident#1 two spoonsful of Jello. Resident #1 took more than three sips of water and took two sips of his shake supplement. Resident #1 refused to eat any more food from his plate. The Medical Records Staff asked Resident#1 if he would like chicken noodle soup. Resident #1 agreed, and the Medical Records Staff fed Resident#1 two spoonsful of chicken noodle soup while she stood over him. During an interview on 10/24/25 at 1:10 pm, the Medical Records Staff stated that she did rounds during meals to see if the residents needed help with their meals. The Medical Records Staff stated Resident #1 had to have the meals set-up and cued to eat. Medical Records Staff stated she had not realized she was standing and was trying to help assist residents during meals. During an interview on 10/24/25 at 2:20 pm, LVN A stated when assisting a resident with meals staff should sit down with the residents and not stand over the residents. During an interview on 10/24/25 at 2:30 pm, CNA B stated for Resident #1, staff should set-up his tray and tell him where everything was located. CNA B stated that when feeding residents staff should sit at eye level and not stand over residents. During an interview on 10/24/25 that started at 2:40 pm, CNA C stated when feeding residents staff should sit down to feed residents because it is a dignity concern when standing over residents. CMA E stated Resident#1 was supposed to have his tray set-up and cued. During an interview on 10/24/25 at 2:55pm, the DON stated staff were supposed to sit down and be able to be at eye level with the residents. The DON stated staff could have conversations with the residents. The DON stated Resident #1 was supposed to be cued and encouraged to eat his meals. Record review of the facility's policy, undated, titled: Section: Quality of care. Subject: ADL., services to carry out reflected,. It is the policy of the facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident in accordance with a written plan of care Record review of facility admission packet, revised 02/2022 reflected: .you have the right to be treated with respect and dignity.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #1) of 6 residents, reviewed for care plans. 1. The facility failed to follow the care plan and assess Resident #1 for pain at the start of each shift since 09/17/25. These failures could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being.Findings Included:Record review of Resident #1's face sheet, dated 09/25/25, reflected an [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1 had diagnoses of Dementia (decline in memory, thinking, problem-solving, and reasoning), Cognitive Communication Deficit (difficulty with communication), Type 2 Diabetes (body cannot use insulin properly or produce it), Essential Hypertension (high blood pressure), Heart Failure, Muscle Weakness, Peripheral Vascular Disease (blood vessels typically in the legs become narrowed or blocked), and a history of falling.Record review of Resident #1's Initial MDS Assessment, dated 09/09/5, reflected Resident #1 had a BIMS score of 07, which indicated Resident #1 had severe cognitive impairment. The MDS Assessment noted a pain assessment was completed upon admission, and no pain was noted.Record review of Resident #1's Care Plan reflected the following: Has acute/chronic pain r/t PVDDate initiated 09/08/2025Monitor/document for probable cause of each pain episode. Remove/limit causeswhere possible.Pain assessment every shift.In an interview on 09/25/25 at 2:40 PN, the DON Trainee stated if the care plan stated Resident #1 was to be assessed for pain every shift, then staff should have assessed for pain every shift, and those assessments would have been documented. She stated the nursing staff would be responsible for checking and documenting the pain level of residents. The DON Trainee stated the risk of not completing pain assessments as noted on the care plan was the resident could be in pain and staff would not be aware. The DON Trainee stated she would provide verification of the documented pain levels. Record review of a document titled, Weights and Vitals Summary dated 09/25/25, reflected the following dates and times for pain level checks:09/08/25 16:03 (4:03 PM) Pain Level noted as 009/09/25 16:19 (4:19 PM) Pain Level noted as 009/10/25 16:12 (4:12 PM) Pain Level noted as 009/11/25 16:12 (4:12 PM) Pain Level noted as 009/12/25 15:34 (3:34 PM) Pain Level noted as 009/13/25 6:06 (6:06 AM) Pain Level noted as 009/14/25 7:11 (7:11 AM) Pain Level noted as 009/15/25 15:23 (3:23 PM) Pain Level noted as 009/16/25 15:44 (3:44 PM) Pain Level noted as 009/17/25 15:23 (3:23 PM) Pain Level noted as 009/18/25 15:40 (3:40 PM) Pain Level noted as 009/19/25 15:36 (3:36 PM) Pain Level noted as 109/20/25 10:20 (10:20 AM) Pain Level noted as 009/23/25 11:52 (11:52 AM) Pain Level noted as 609/23/25 15:00 (3:00 PM) Pain Level noted as 0In an interview on 09/25/25 at 4:02 PM, the Administrator stated that care planning was on the nursing side, but everything on the care plan should be followed to ensure the best care for the resident.Record review of the facility's policy titled, Care Planning, dated 07/2020, reflected the following: Policy:It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident.The resident's plan of care focus, goals, and interventions are communicated and implemented by the members of the health care continuum accordingly.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 Medication Carts (Medication Cart #1) reviewed for pharmacy services. 1. The facility failed to ensure Medication Cart #1 did not include discontinued medication, Lorazepam (Ativan) for Resident #1 after it was discontinued on 09/19/25. This failure could place residents at risk of receiving discontinued medication and possible adverse reactions.Findings Include:Record review of Resident #1's order summery on the electronic record, dated 09/25/25, reflected Lorazepam Oral Tablet 0.5 MG was discontinued.Record review of Resident #1's September 2025 Medication Administration Record reflected the Lorazepam was discontinued on 09/19/25.Record review of a progress note completed by the ADON on Resident #1's electronic record, dated 09/19/25, reflected the following: [Family Member does not [Resident #1] to take Ativan in fear of her becoming drowsy. This nurse states to her that I will reach out to [NP]. This nurse notifies NP with concerns from the [Family Member], and new order to discontinue Ativan 0.5mgIn an observation and interview on 09/25/25 at 1:55 PM, the Lorazepam was observed still on the cart for Resident #1. LVN A stated the Lorazepam was discontinued and she guessed it should be removed from the medication cart. She stated she understood the risk of discontinued mediation on the cart and would remove it. LVN A stated the risk was possible drug diversion. In an interview on 09/25/25 at 3:53 PM, the DON Trainee stated she started working at this facility some days ago and was not sure about their policy on discontinued medications, but from her training discontinued drugs should be quickly removed from the cart and destroyed to avoid issues like giving a discontinued medication to a resident. The DON Trainee stated the ADON would know the facility policy on discontinued medication.In an interview on 09/25/25 at 3:56 PM, the ADON stated the discontinued medications were given to the DON, but the DON was on leave. She stated the nurses who were responsible for the medication cart would continue to count the medication until the DON returned. The ADON stated the DON was the only one who had the key to the narcotic closet. The ADON stated she felt there was no risk of the discontinued medication that remained on the medication cart, because the nurses continued to count the medication to ensure there was no drug diversion.In an interview on 09/25/25 at 4:02 PM, the Administrator Trainee stated she would follow-up with the DON regarding discontinued medication when she returned. She stated she did not know much about medications like the DON would know and was not sure of the specific risks.Record review of the facility's policy, titled, Medication Access and Storage / Drug Destruction, dated 7/2023, reflected the following: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists. Medication destruction is to be handled in accordance with CMS and Texas Administrative codes on Pharmacy and Drug Destruction. Narcotics are given to the Director of Nursing for destruction. They are inventoried and counted and kept under a double lock system until medication destruction can be completed with the Consultant Pharmacist.

Based on observations, interviews, and record review the facility failed to make sure that residents receive adequate respiratory care (including tracheostomy care and tracheal suctioning) for 3 of 5 Residents (Resident#1, Resident#2 and Resident#3), reviewed for infection control. The facility failed to ensure that Resident #1, Resident #2 and Resident #3's oxygen tubing and prefilled humidifier water bottles were changed and dated. The facility failed to ensure that Resident #3's oxygen tubing was bagged in a plastic bag and stored in a drawer. The failures had the potential to affect residents receiving oxygen therapy by increasing their risk of health -associated infections.Findings included:Record review of Resident 1#'s Quarterly MDS Assessment, dated 09/01/, 2025 reflected the resident was a [AGE] year-old male, had a BIMs score of 07 indicating he was cognitively impaired. The resident had diagnoses which included Renal Insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys caused by renal artery disease), Diabetes Mellitus (is a condition that happens when your blood sugar is too high. It develops when your pancreas doesn't make enough insulin or any at all, or when your body isn't responding to the effects of insulin properly. Diabetes affects people of all ages. Most forms of diabetes are chronic (lifelong), and all forms are manageable with medications and/or lifestyle changes.), Non-Alzheimer's Dementia (syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities. This typically involves problems with memory, thinking, behavior, and motor control) Asthma (asthma is a condition that causes long-term (chronic) inflammation in your airways. The inflammation makes them react to certain triggers, like pollen, exercise or cold air. During these attacks, your airways narrow (bronchospasm), swell up and fill with mucus. This makes it hard to breathe or causes you to cough or wheeze. Without treatment, these flare-ups can be fatal.) Record review of Resident #1's Comprehensive Care Plan, Date Initiated: 12/18/2024 and Revision on: 12/18/2024 reflected the resident had Oxygen/BIPAP Therapy r/t Respiratory illness. Facility intervention includes: BIPAP PER ORDERS. Encourage or assist with ambulation as indicated. Give medications as ordered by physician. Monitor/document side effects and Effectiveness. Monitor for s/sx of respiratory distress and report to MD.Record review of Resident #1's Physician orders start date 01/08/2025 reflected O2 at 2 l/min continuous per nasal cannula every shift for COPD related to chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs. The damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs. This limited airflow is known as obstruction. Symptoms include trouble breathing, a daily cough that brings up mucus and a tight, whistling sound in the lungs called wheezing).Record review of Resident 2#'s Quarterly MDS Assessment, dated 09/04/2025, reflected the resident was a [AGE] year-old female, had a BIMs score of 14 indicating she was cognitively intact. The resident had diagnoses which included anemia (Anemia is a blood disorder that happens when you don't have enough red blood cells or your red blood cells don't work as they should. Some types of anemia are inherited, but people may also acquire or develop the condition during their lifetimes), respiratory failure (Respiratory failure is a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia). You might also hear people use the term acute hypoxemic respiratory failure (AHRF) to describe it.), chronic respiratory failure with HYP (Respiratory failure is a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia). You might also hear people use the term acute hypoxemic respiratory failure (AHRF) to describe it.), and asthma (Asthma is a condition that causes long-term (chronic) inflammation in your airways. The inflammation makes them react to certain triggers, like pollen, exercise or cold air. During these attacks, your airways narrow (bronchospasm), swell up and fill with mucus. This makes it hard to breathe or causes you to cough or wheeze. Without treatment, these flare-ups can be fatal).Record review of Resident #2's Comprehensive Care Plan, Date Initiated: 07/29/2025: Has Oxygen Therapy. Facility interventions: Give medications as ordered by physician. Monitor/document side effects and effectiveness, If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to the usual oxygen delivery method after the meal. Monitor for s/sx of respiratory distress and report to MD PRN. Record review of Resident #2's Physician's orders start date 05/04/2025 reflected, change O2 tubing & humidifier bottle every night shift every Sun.Record review of Resident 3#'s Quarterly MDS Assessment, dated [DATE], reflected the resident was a [AGE] year-old female, had a BIMs score of 15 indicating he was cognitively intact. The resident had diagnoses which included anemia (anemia is a blood disorder that happens when you don't have enough red blood cells or your red blood cells don't work as they should. Some types of anemia are inherited, but people may also acquire or develop the condition during their lifetimes), chronic respiratory failure with HYP((Respiratory failure is a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia). You might also hear people use the term acute hypoxemic respiratory failure (AHRF) to describe it.), asthma (Asthma is a condition that causes long-term (chronic) inflammation in your airways. The inflammation makes them react to certain triggers, like pollen, exercise or cold air. During these attacks, your airways narrow (bronchospasm), swell up and fill with mucus. This makes it hard to breathe or causes you to cough or wheeze. Without treatment, these flare-ups can be fatal) , and shortness breathe (Shortness of breath can be a sign of some medical conditions, including asthma, COPD and heart failure, as well as anxiety or panic attacks. The long-term lung effects of smoking may first be noticed as worsening shortness of breath).Record review of Resident #3's Comprehensive Care Plan, Date Initiated 10/10/2025 Has Oxygen Therapy. Facility includes Give medications as ordered by physician. Monitor/document side effects and effectiveness. Revision on: 10/10/2025: Has Oxygen Therapy. Facility interventions: Give medications as ordered by physician. Give medications as ordered by physician. Monitor/document side effects and effectiveness, Oxygen per MD orders.Record review of Resident #3's Physician orders start date 10/12/2025 reflected, change O2 tubing & humidifier bottle every night shift every Sun.Observation on 10/16/2025 at 11:05AM of Resident# 2 revealed the oxygen tubing was not dated or labeled. Observation 10/16/2025 at 11:17AM of Resident# 3 revealed the oxygen tubing and prefilled humidification bottle were not dated. Interview with Resident #3 revealed that sometimes they changed oxygen tubing, but it had not been changed the past week.Observation 10/16/2025 at 11:30AM of Resident# 1 revealed the oxygen tubing and prefilled humidification bottle were not dated and oxygen tubing was on the floor. Interview 10/16/2025 at 1:02PM with LVN A revealed that she was Resident #1 and Resident #2's nurse. She stated that she was not aware that the oxygen tubing and the prefilled humidifier bottles were not dated. She stated that she usually checked the oxygen tubing to make sure they were dated. She stated that the oxygen tubing and prefilled humidifier were changed every week on Sunday night and PRN. She stated it was important to date all tubing so that everyone track when the tubing was last changed. She stated that it was important to change tubing every week, and store tubing in plastic bags and place in the drawers to prevent contamination and infections. She stated that she had been in service on infection control and oxygen tubing care.Interview 10/16/2025 at 1:34pm with LVN B revealed that oxygen tubing was supposed to be changed on Sunday night shift. She stated she usually checked the oxygen tubing and prefilled humidifier bottlers to make sure they were dated. She stated she was not aware that Resident #3's oxygen tubing and the prefilled humidifier bottle were not dated. She stated the importance of dating oxygen tubing was to track its age so it could be replaced according to the recommended schedule. She stated that she had been in service on infection control and oxygen tubing care.Interview 10/16/2025 at 4:30PM with DON revealed her expectation was the nurse assigned should be check the oxygen tubing and prefilled humidification bottles as part of overall assessment make sure it was properly functioning. She stated oxygen tubing was changed weekly on the night shift and if the night shift were busy then any shift could change. She stated all oxygen tubing and prefilled humidification bottles should be dated. She stated that all oxygen tubing should be stored in a plastic bag. She stated the risk to the resident if tubing was not dated or stored in sanitary ways was infection control. She stated that the nurses had been in serviced on infection control and oxygen tubing care.The facility policy titled Infection Control and Policy/Procedure Reviewed July 2022 reflected:The goal of the infection control program is to:a. Decrease the risk of infection to patients and personnelb. Monitor for the occurrence of infection and implement appropriate control measuresc. Identify and correct problems relating to infection control practicesd. Ensure compliance with state and federal regulations to infection control.The facility policy titled Oxygen Equipment Revised May 2017 reflected:It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner and to use disposable pre-filled humidifiers, tubing, mask, and cannulas for residents receiving oxygen. The equipment is to be discarded. The facility will maintain clean tanks, connectors, and concentrators.Procedures:1. Oxygen Tanks, connectors, and concentratorsa. Oxygen tanks, connectors and concentrators must be cleaned after use.b. Gauges must be cleaned after use as a follows:1. Remove gauge from tank.2. Clean gauge with disinfectants. Allow to dry thoroughly.3. Place clean Guage in oxygen storage area.C. pre-filled humidifiers, when used, are to be dated and replaced every (7) days, according to manufacturers' recommendations, or as needed.1. Tubing should be replaced every week.2. Masks should be replaced every week.3. Cannulas should be replaced every week.4. Oxygen concentrator filters will be cleaned with water and detergent every week according to manufacturer's recommendations.D. Oxygen masks, nasal cannulas, and tubing will be used for one resident only. When used continuously or intermittently, tubing will be routinely changed to prevent the build-up of respiratory secretions, mucous, and bacterial growth.E. When a mask or cannula is temporarily not being used it will be covered loosely to prevent contamination from airborne microorganisms. It will not be covered tightly.

Based on observation, interview, and record review, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay that included diagnoses, course of treatment, pertinent labs, a final summary of the resident's status and reconciliation of all pre-discharge medications with the resident's post-discharge medications for 1 of 5 residents (Resident #1) reviewed for closed records. The facility failed to ensure Resident #1 discharged the facility with a discharge summary that included an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions to ensure that care is coordinated and the resident transitions safely from one setting to another. This failure could place residents at risk for not receiving appropriate and timely care due to confusion among various facilities, agencies, practitioners, and caregivers involved with the resident's care. Findings Included:Record review of Resident #1's face sheet dated 09/09/2025, reflected the [AGE] year-old female resident was admitted to the facility on [DATE]. Diagnoses included: cerebrovascular disease (a condition that affects blood vessels in the brain, leading to reduced blood flow and oxygen to the brain), type 2 diabetes mellitus without complications (a chronic condition characterized by high blood sugar levels), adjustment disorder with anxiety (a mental health condition characterized by excessive worry, nervousness and fear), morbid obesity, hemiplegia affecting left side (paralysis or severe weakness on one side of the body), cerebral infarction (blood flow to the brain is interrupted, resulting in cell death and brain damage), muscle wasting and atrophy (the loss of muscle mass and strength). Further review of the Resident #1's MDS, dated [DATE], revealed the resident's BIMS score was 12, indicating moderately impaired cognitive function. The resident used a wheelchair and required assistance for transfers, showering, personal hygiene and toileting. The resident was incontinent of bowel and bladder. A record review of Resident #1's progress notes revealed the resident discharged the facility on 09/03/2025. The final progress note stated the following: Resident discharged from facility with daughter [NAME] and transported to a care home in [NAME] called A place like home. Resident left in stable condition. Resident/daughter [NAME] stated no questions/concerns on departure. Resident left with medications/facesheet. Resident has all her belonging. Room empty. Will inform oncoming nurse. Record review of Resident #1's Comprehensive Care plan initiated 05/27/2025 and closed 09/05/2025 revealed the following: Focus: At risk for impaired cognitive function or impaired thought processes r/t prior CVA and new environment. Goal: Will maintain current level of cognitive function through the review date. Interventions included: Engage in simple, structured activities that avoid over demanding tasks. During an interview with the SSD on 09/09/2025 at 2:20 PM, the SSD confirmed that Resident #1 did not have a discharge summary in her closed electronic records. When asked who is responsible for charting the discharge summary, the SSD stated it was her responsibility to initiate it. When asked why the discharge summary for Resident #1 was not completed, the SSD stated she was not sure why she didn't do it or how she missed it. Record review of the facility's Discharge Process policy, latest revision dated 07/2015, stated the following: It is the policy of this facility that the Social Service Designee and/or Case Manager, with consultation from the Interdisciplinary Team, shall provide a discharge planning service and process, for each resident admitted , that identifies and evaluates the resident's needs and assists him/her in moving from one environment to another. The purpose of discharge planning is to ensure that each resident has a planned program of continuing care, which meets his/her post discharge plan of needs.

Based on observation, interview, and record review, the facility failed to ensure the residents had secure and confidential personal and medical records.for one (Residents #1) of 7 residents reviewed for confidentiality of records. The facility failed to ensure LVN A did not leave Residents #1's medication blister cards on top of an unattended Medication cart on the 100 hall, while she was in Resident #2's room with the door closed. This failure could place all residents at risk of having their medical information disclosed to visitors and other residents, causing embarrassment, frustration, decreased privacy and psycho-social well-being. The findings included: Record review of Resident #1's Admission MDS Assessment completed on 03/20/25 revealed a [AGE] year-old male who admitted [DATE] with a BIMS Score of 13 (No cognitive impairment), one sided upper and lower extremity impairments and he used a wheelchair. He was dependent (Helper did all the help) with ADLs, rolling from left to right and transfers. He was always incontinent to bowel and bladder and had medically complex conditions. He had active diagnoses of atrial fibrillation, hypertension, renal insufficiency, diabetes mellites, aphasia, CVA/TIA, hemiplegia, malnutrition, anxiety, gastronomy, cognitive communication deficit, muscle weakness and dysphagia. He received scheduled pain medications and had recent surgery requiring nursing Skilled Nursing home stay for the GI tract or abdominal contents. He had an application of surgical dressings other than feet, took anti-depressant, anti-psychotic, anti-platelet and anti-convulsant medications. Record review of Resident #1's Physician Order Report printed 05/07/25 revealed 8:00 am was the time these medications were ordered to be given: Buspirone Oral Tablets 5 MG: Give 1 tablet via G-Tube three times a day for ANXIETY AEB AGITATION/RESTLESSNESS related to ANXIETY DISORDER, Pantoprazole Sodium Oral Tablets Delayed Release 40 MG: Give 1 tablet via Gtube two times a day related to DYSPHAGIA, OROPHARYNGEAL PHASE, Gabapentin Capsules 100 MG Give 1 capsule via Gtube three times a day related to MUSCLE WASTING AND ATROPHY, Escitalopram Oxalate Oral Tablets 10 MG: Give 1 tablet via G-Tube one time a day for DEPRESSION AEB: SELF ISOLATION related to ADULT FAILURE TO THRIVE, Metoprolol Tartrate Oral Tablet Give 12.5 mg via G-Tube two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION. Record review of Resident #1's MARs for May 2025 revealed an 8:00 am time to administer his medications and LVN A initialed on 05/07/25 giving this resident, Buspirone Oral Tablet 5 MG: Give 1 tablet via G-Tube three times a day for ANXIETY AEB: AGITATION/RESTLESSNESS related to ANXIETY DISORDER, UNSPECIFIED. Escitalopram Oxalate Oral Tablet 10 MG: Give 1 tablet via G-Tube one time a day for DEPRESSION AEB: SELF ISOLATION related to ADULT FAILURE TO THRIVE. Metoprolol Tartrate Oral Tablet: Give 12.5 mg via G-Tube two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION. Pantoprazole Sodium Oral Tablet Delayed Release 40 MG: Give 1 tablet via G-Tube two times a day related to DYSPHAGIA, OROPHARYNGEAL. Gabapentin Capsule 100 MG Give 1 capsule via G-Tube three times a day related to MUSCLE WASTING AND ATROPHY. (Dantrolene Sodium Oral Capsule 25 MG: Give 1 capsule via G-Tube every evening shift for Severe Pain was on the unattended medication cart but was not initialed on the MAR as being given). Observation on the 100 hall on 05/07/25 at 10:35 am revealed, six of Resident #1's Medications on top of a Medication cart that was located in front of Resident #1's doorway. The medication cart was unattended for about one minute with Resident #1's name and his medications: Buspirone Oral Tablets 5 MG, Pantoprazole Sodium Oral Tablets Delayed Release 40 MG, Gabapentin Capsules 100 MG, Escitalopram Oxalate Oral Tablets 10 MG, Dantrolene Sodium Oral Capsule 25 MG, Metoprolol Tartrate Oral Tablet 12.5 mg. Observation and interview on 05/07/25 at 10:36 am revealed, LVN A opened the door of Resident #2's room and walked across the hallway to the medication cart in front of Resident #1's room. LVN A grabbed Resident #1's six medication cards and she was about to put them into the med cart. She stated she had just popped Resident #1's medications and gave them to him and heard Resident #2 yelling needing help. She stated she just ran over there to check on Resident #2 to adjust her O2 mask. She stated she should have put Resident #1's medication cards back into the medication cart to secure them before leaving the med cart. She stated she normally did not leave medications unattended on the medication carts but a resident was yelling. She stated leaving medications unattended could cause a HIPAA violation because the resident's names and medication names were on the medication cards. She stated the other residents would know what the resident's medications were or the residents could try to swallow the medications and they could get sick. She stated what each of the six medications were and reason why they were needed and said she mistakenly took out the Dantrolene Sodium medication but did not give to him because he only took that one at night. She stated once she adjusted Resident #2's O2 mask, she was fine. Interview on 05/07/25 at 1:12 pm, LVN B stated she never left the resident's medication cards on the med cart unattended because they had other people that walk around and the medications could end up ingesting the meds. She stated their medications were supposed to be locked up in the med cart, because it was a HIPAA violation. She stated the residents' names and personal information were on their medication cards. She stated they had a training today (05/07/25) about keeping the med carts locked and to not turn their back or step away from the med carts and not to leave the medication out. She stated they needed to prevent others from getting to the resident's medication because something could happen to the medications. She stated if they left medications out, it would fall on the nurses and medication aides. She stated medications left out could cause them to easily get grabbed by anyone. Interview on 05/07/25 at 2:41 pm, LVN C stated she had not ever left medications on top of the med cart because it could result in a medication error if a resident picked up the medications and took them. She stated a resident might pick the medications up thinking they were candy or an employee or visitor could take the medications. She stated leaving medications out, could lead to suspension, in-service trainings, counseling, or termination. She stated leaving medication unattended could be a HIPAA violation because anyone could see what types of medications the residents took. She stated the last HIPAA and medication administering trainings was earlier this year. Interview on 05/07/25 at 4:41 pm, the DON stated the facility had no issues with HIPAA violations but today they did, involving LVN A leaving a resident's medication on the medication cart unattended. She stated anyone could have passed by her med cart, and the residents or anyone could have taken them off of LVN A's med cart. She stated the nurses were responsible to ensure the medications administered were inside, and locked in the medication cart before they left their medication carts. Interview on 05/07/25 at 5:18 pm, Medical Records D stated they had no issues HIPAA violations of the residents records of which she was aware. She stated for any HIPAA violation issues she would notify the Administrator about it. She stated it was a part of her and the administrator's jobs to ensure the facility was HIPAA compliant. She stated it was a HIPPA violation if a resident's medications were left unattended on the med carts. She stated if she saw that she would stand next to the med cart until that nurse arrived back to it, then report it to the Administrator. She stated today (05/07/25) this morning she saw the medication cart on the 100 hall and saw LVN A coming out of a resident's room and walking to the medication cart. She stated she asked LVN A about getting a wheelchair for a resident and did not realize a resident's medication cards were on the med cart. She stated she saw the HHSC Surveyor standing on the other side of the med cart. She stated leaving medications unattended could cause someone to use the information on the medication card to open up another medication account. She stated the information on the medication cards could be used for personal benefit because the resident's name, date of birth, medication name and dosages were on them. Interview on 05/07/25 at 5:29 pm, the Administrator stated it was brought to her attention today (05/07/25) that LVN A was getting ready to give Resident #1 his medications and Resident #2 located across the hall needed assistance. She stated LVN A went to Resident #2's room and left Resident #1's medications on top of the med cart. She stated LVN A did not follow the facility's protocol because all medications needed to be secured at all times and locked in the med cart or being given to the resident. She stated today (05/07/25) they did an in-service training with all nursing staffing and medication aides. She stated they trained the staff not to leave medications on the medication carts and to put them in the med cart locked. She stated leaving medications out could lead to different things, a resident could get them or result in a drug diversion. She stated for HIPAA violations, she was responsible, nurse administration and nurses were responsible for ensuring they were HIPAA compliant. She stated not leaving medications unattended on medication carts was nursing school 101 and LVN A knew because it could cause a breach in a resident's identity. She stated she and the DON spoke to LVN A by doing a 1 on 1 meeting with her to never leave medications on top of the med carts. She stated LVN A said while administering Resident #1's medications, she went to see about Resident #2 and repositioned her. She stated when she returned back to her med cart the HHSC state lady was standing right next to it. She stated LVN A said she was not all the way down the hall or in the dining room She stated her expectation for HIPAA was for the staff to keep the resident's medications confidential. Record review of LVN A's Counseling Disciplinary Notice dated unsigned by LVN A or nurse management revealed, LVN A's Date of hire: 05/29/24, date of notice: 05/07/25. Type of action being taken: Final written/warning*. 2. Reason (s) why counseling/disciplinary action is necessary, including a complete explanation of the conduct constituting the violation. If additional space is required please see attach a separate sheet. Employee is expected to keep medications secured in nurses cart at all times. No exceptions. Record review of the Facility's Training dated 05/07/25 with nine signatures including LVN A's signature revealed, Medication must be locked in cart when cart is left unattended. Only licensed nurses and Certified Medication Aides may have access to medication cart. Cart should be clean and organized. If nurses are to step away from cart for any reason, med must be stored and cart must be locked. Record review of the Facility's Resident Right policy amended 07/13/17 revealed, Privacy and confidentiality: Secure and confidential personal and medical records. Record review of the Facility's Resident/Patient confidentiality policy undated revealed, Policy: All resident health information is confidential and protected by HIPAA law. HIPPA definition - The Health Insurance Portability and Accountability Act. HIPAA is a federal law that is designed to protect the privacy and security of patient health information. Privacy rule: The HIPAA privacy Rule establishes national standards to protect individuals' medical records and other personal health information .All staff, volunteers, and vendors must not disclose any medical information about a resident, either verbally, written or electronically.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for one resident (Resident #1) of 9 residents reviewed for pharmacy services. The facility failed to ensure Resident #1 received 5 of his routine doctor ordered medications between 7:00 am and 9:00 am on 05/07/25; subsequently they were not given to him until around 10:35 am. This failure placed residents at risk of not receiving the physician ordered medications on time, which could cause the residents to have a change of condition, resulting in a decreased quality of life and psychosocial well-being. Findings Included: Record review of Resident #1's Admission MDS Assessment completed on 03/20/25 revealed a [AGE] year-old male who admitted [DATE] with a BIMS Score of 13 (No cognitive impairment), one sided upper and lower extremity impairments and he used a wheelchair. He was dependent (Helper did all the help) with ADLs, rolling from left to right and transfers. He was always incontinent to bowel and bladder and had medically complex conditions. He had active diagnoses of atrial fibrillation, hypertension, renal insufficiency, diabetes mellites, aphasia, CVA/TIA, hemiplegia, malnutrition, anxiety, gastronomy, cognitive communication deficit, muscle weakness and dysphagia. He received scheduled pain medications and had recent surgery requiring nursing Skilled Nursing home stay for the GI tract or abdominal contents. He had an application of surgical dressings other than feet, took anti-depressant, anti-psychotic, anti-platelet and anti-convulsant medications. Record review of Resident #1's Care Plan date initiated 11/24/25 revealed, He had a Cerebral vascular accident (stroke) related to embolism, hemiplegia/hemiparesis of left side related to stroke, hypertension related to CVA, nutritional problem related to acute kidney injury, type 2 diabetes mellitus and new peg tube, had an actual fall with no injury related to poor balance from right hemiplegia, acute/chronic pain, cardiovascular status related to arrhythmia, diabetes mellitus, ADL self-care deficit related to new admission and limited mobility, anti-anxiety related to anxiety disorder, at risk for a communication problem related to expressive aphasia, weak or absent voice. On 03/13/25 at risk for falls related to mobility deficits and impaired cognitive function or thought processes related to history of CVA. Record review of Resident #1's Physician Order Report printed 05/07/25 revealed 8:00 am was the time these medications were ordered to be given: Buspirone Oral Tablets 5 MG: Give 1 tablet via G-Tube three times a day for ANXIETY AEB AGITATION/RESTLESSNESS related to ANXIETY DISORDER, Pantoprazole Sodium Oral Tablets Delayed Release 40 MG: Give 1 tablet via Gtube two times a day related to DYSPHAGIA, OROPHARYNGEAL PHASE, Gabapentin Capsules 100 MG Give 1 capsule via Gtube three times a day related to MUSCLE WASTING AND ATROPHY, Escitalopram Oxalate Oral Tablets 10 MG: Give 1 tablet via G-Tube one time a day for DEPRESSION AEB: SELF ISOLATION related to ADULT FAILURE TO THRIVE, Metoprolol Tartrate Oral Tablet Give 12.5 mg via G-Tube two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION. Record review of Resident #1's MARs for May 2025 revealed an 8:00 am time to administer his medications and LVN A initialed on 05/07/25 giving this resident, Buspirone Oral Tablet 5 MG: Give 1 tablet via G-Tube three times a day for ANXIETY AEB: AGITATION/RESTLESSNESS related to ANXIETY DISORDER, UNSPECIFIED. Escitalopram Oxalate Oral Tablet 10 MG: Give 1 tablet via G-Tube one time a day for DEPRESSION AEB: SELF ISOLATION related to ADULT FAILURE TO THRIVE. Metoprolol Tartrate Oral Tablet: Give 12.5 mg via G-Tube two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION. Pantoprazole Sodium Oral Tablet Delayed Release 40 MG: Give 1 tablet via G-Tube two times a day related to DYSPHAGIA, OROPHARYNGEAL. Gabapentin Capsule 100 MG Give 1 capsule via G-Tube three times a day related to MUSCLE WASTING AND ATROPHY. (Dantrolene Sodium Oral Capsule 25 MG: Give 1 capsule via G-Tube every evening shift for Severe Pain was on the unattended medication cart but was not initialed on the MAR as being given). Observation and interview on the 100 hall on 05/07/25 at 10:36 am revealed, LVN A opened the door of Resident #2's room and walked across the hallway to the medication cart in front of Resident #1's room. LVN A grabbed Resident #1's six medication cards and she was about to put them into the med cart. She stated she had just popped Resident #1's medications and gave them to him. Interview on 05/07/25 at 1:12 pm, LVN B stated the timeframes for giving the residents' 8:00 am medications was an hour before or after the time they were Doctor ordered. She stated she was not sure what to do if medications were given outside of that timeframe because she had not had that issue and would have to ask the DON. Interview on 05/07/25 at 2:10 pm, LVN A stated Resident#1 had right sided weakness and needed assistance with all of his ADL's. She stated Resident #1 was verbally able to make his needs known but was not able to really move right now. She stated he was a resident who had a G-tube and the nurses had to monitor his fluid intake. She stated she gave Resident #1 his first dose of medications around 8:20 am this morning (05/07/25) then he received his second round of medications around 11:00 am). She stated the nurses had an hour before and 1 hour after to give the residents their medications. She stated Resident #1's medications were ordered to be given at 8:00 am and should have been given by 9:00 am. She stated she had 32 residents on her hall and she started administering medications at the far end of the hall and worked toward the nurses station. She stated she had four residents with G-tubes and sometimes the hospice nurses had to talk to her about the residents which was time consuming. She stated she had three oxygen dependent residents and the reason the medications were given late was just a timing issue. She stated the nurses had a training today (05/07/25) about administering the resident's medications within the 1 hour before or after it was ordered. She stated she was not sure of the exact time, but last year, the nurses had a medication administering training about the 5 Rights: right patient and right time. She stated she was not sure what to do if the resident's medications were given late and was not sure how that could affect the residents. She stated their pain may not be controlled effectively or the resident could have a change in condition. She stated she had a lot to do and her hall had 32 residents and one medication aide. She stated a lot of her residents took blood thinners and took medications for seizures, diabetes, and pain. Interview on 05/07/25 at 2:41 pm, LVN C stated the timeframes for giving the resident's their medications was an hour before and after it was ordered. She stated the resident's medications was prescribed based on their medical diagnoses. She stated if a resident was not given their medications on time depended on the situation. She stated she had not had a problem giving medications their medications outside of the parameters. She stated the Residents could have adverse reactions if medications were not given timely. She stated she had not had any trainings on what to do if the nurses got behind schedule. Interview on 05/07/25 at 4:41 pm, the DON stated the parameters for medication administering was an hour before or an hour after it was Doctor ordered. She stated they had no issues with the nurses not giving the residents their medications on time until today (05/07/25). She stated she was not sure if Resident #1 received his medications on time today. She stated it depended on the orders on how it could affect the residents if medications were given late. She stated if LVN A was busy, she should have reached out for the Doctor to see if it was okay to give the residents medications late. She stated not getting medications on time could cause anxiousness increase chances of the resident falling. She stated the resident could become anxious and fidget by moving around and have increased pain and undo stress. She stated the resident's blood pressure could get too high and they could have a heart attack resulting in a change of condition. She stated the nurses were responsible for ensuring the resident's medications were given on time but ultimately she was responsible. She stated she would expect the nurses and medication aides informed her if they were running behind with medication pass. Interview on 05/07/25 at 5:29 pm, the Administrator stated she was not aware LVN A gave Resident #1 his medications late. She stated she would have to talk to the DON and ADON about that, and that it was the nurses responsibility to give the residents their medications within the med pass parameters. She stated giving the residents their medications late depended on what the medication was taken for. She stated in Resident #1's case if his medications were given late, it could cause him to be more anxious. She stated each medication had different risks if they were not taken as Doctor ordered. She stated the expectation for medication administering was for the nursing staff to administer the resident's medications on time, and if they could not, they needed to let the DON ADON know. Record review of the facility's undated Med Pass times for 100 hall and 200 hall revealed, Daily 8 am. Record review of the facility's undated Med Pass times for G-Tube Meds Time Codes undated revealed, QD 8 am. Record review of the facility's Medication Administration policy revised 07/2020 revealed, Policy: It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Procedures: 2. Medications must be administered in accordance with the written orders of the attending physician .5. Scheduled medications must be administered within the facility time frame .7. If a medication is withheld, refused, or given other than the scheduled time, the documentation will be reflected in the clinical record .The seven rights of medication administering are as follows in order to ensure safety and accuracy of administration .1. Right resident, 2. Right time, 3. Right medication, 4. Right dose, 5. Right route, 6. Right documentation, 7. Right diagnosis. Record review of the facility's Pharmacy Services/ Nursing Services: Physician Orders revised 07/2022 revealed, Policy: It is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. It is the policy of this facility to accurately implement orders in addition to medication orders (treatment procedures) only upon the written order of licensed and authorized to do in accordance with the resident's plan of care. Procedures: 2. All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. The signing of orders shall be by signature or a personal computer key.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were in locked compartments for 1 (Residents #1) of 7 residents reviewed for medication storage. The facility failed to ensure LVN A did not leave Residents #1's medication blister cards on top of an unattended Medication cart on the 100 hall, while she was in Resident #2's room with the door closed. This failure could place all residents at risk of having their medications taken or consumed by other residents, which could cause a shortage of their medications or cause a change in their medical condition resulting in a decline in their health and psycho-social well-being. The findings included: Record review of Resident #1's Admission MDS Assessment completed on 03/20/25 revealed a [AGE] year-old male who admitted [DATE] with a BIMS Score of 13 (No cognitive impairment), one sided upper and lower extremity impairments and he used a wheelchair. He was dependent (Helper did all the help) with ADLs, rolling from left to right and transfers. He was always incontinent to bowel and bladder and had medically complex conditions. He had active diagnoses of atrial fibrillation, hypertension, renal insufficiency, diabetes mellites, aphasia, CVA/TIA, hemiplegia, malnutrition, anxiety, gastronomy, cognitive communication deficit, muscle weakness and dysphagia. He received scheduled pain medications and had recent surgery requiring nursing Skilled Nursing home stay for the GI tract or abdominal contents. He had an application of surgical dressings other than feet, took anti-depressant, anti-psychotic, anti-platelet and anti-convulsant medications. Record review of Resident #1's Physician Order Report printed 05/07/25 revealed 8:00 am was the time these medications were ordered to be given: Buspirone Oral Tablets 5 MG: Give 1 tablet via G-Tube three times a day for ANXIETY AEB AGITATION/RESTLESSNESS related to ANXIETY DISORDER, Pantoprazole Sodium Oral Tablets Delayed Release 40 MG: Give 1 tablet via Gtube two times a day related to DYSPHAGIA, OROPHARYNGEAL PHASE, Gabapentin Capsules 100 MG Give 1 capsule via Gtube three times a day related to MUSCLE WASTING AND ATROPHY, Escitalopram Oxalate Oral Tablets 10 MG: Give 1 tablet via G-Tube one time a day for DEPRESSION AEB: SELF ISOLATION related to ADULT FAILURE TO THRIVE, Metoprolol Tartrate Oral Tablet Give 12.5 mg via G-Tube two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION. Record review of Resident #1's MARs for May 2025 revealed an 8:00 am time to administer his medications and LVN A initialed on 05/07/25 giving this resident, Buspirone Oral Tablet 5 MG: Give 1 tablet via G-Tube three times a day for ANXIETY AEB: AGITATION/RESTLESSNESS related to ANXIETY DISORDER, UNSPECIFIED. Escitalopram Oxalate Oral Tablet 10 MG: Give 1 tablet via G-Tube one time a day for DEPRESSION AEB: SELF ISOLATION related to ADULT FAILURE TO THRIVE. Metoprolol Tartrate Oral Tablet: Give 12.5 mg via G-Tube two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION. Pantoprazole Sodium Oral Tablet Delayed Release 40 MG: Give 1 tablet via G-Tube two times a day related to DYSPHAGIA, OROPHARYNGEAL. Gabapentin Capsule 100 MG Give 1 capsule via G-Tube three times a day related to MUSCLE WASTING AND ATROPHY. (Dantrolene Sodium Oral Capsule 25 MG: Give 1 capsule via G-Tube every evening shift for Severe Pain was on the unattended medication cart but was not initialed on the MAR as being given). Observation on the 100 hall on 05/07/25 at 10:35 am revealed, six of Resident #1's Medications on top of a Medication cart that was located in front of Resident #1's doorway. The medication cart was unattended for about one minute with Resident #1's name and his medications: Buspirone Oral Tablets 5 MG, Pantoprazole Sodium Oral Tablets Delayed Release 40 MG, Gabapentin Capsules 100 MG, Escitalopram Oxalate Oral Tablets 10 MG, Dantrolene Sodium Oral Capsule 25 MG, Metoprolol Tartrate Oral Tablet 12.5 mg. Observation and interview on 05/07/25 at 10:36 am revealed, LVN A opened the door of Resident #2's room and walked across the hallway to the medication cart in front of Resident #1's room. LVN A grabbed Resident #1's six medication cards and she was about to put them into the med cart. She stated she had just popped Resident #1's medications and gave them to him and heard Resident #2 yelling needing help. She stated she just ran over there to check on Resident #2 to adjust her O2 mask. She stated she should have put Resident #1's medication cards back into the medication cart to secure them before leaving the med cart. She stated she normally did not leave medications unattended on the medication carts but a resident was yelling. She stated leaving medications unattended could cause other residents to know what the resident's medications were or the residents could try to swallow the medications and they could get sick. She stated what each of the six medications were and reason why they were needed and said she mistakenly took out the Dantrolene Sodium medication but did not give to him because he only took that one at night. She stated once she adjusted Resident #2's O2 mask, she was fine. Interview on 05/07/25 at 1:12 pm, LVN B stated she never left the resident's medication cards on the med cart unattended because they had other people that walk around and the medications could end up ingesting the meds. She stated their medications were supposed to be locked up in the med cart. She stated they had a training today (05/07/25) about keeping the med carts locked and to not turn their back or step away from the med carts and not to leave the medication out. She stated they needed to prevent others from getting to the resident's medication because something could happen to the medications. She stated if they left medications out, it would fall on the nurses and medication aides. She stated medications left out could cause them to easily get grabbed by anyone. Interview on 05/07/25 at 2:41 pm, LVN C stated she had not ever left medications on top of the med cart because it could result in a medication error if a resident picked up the medications and took them. She stated a resident might pick the medications up thinking they were candy or an employee or visitor could take the medications. She stated leaving medications out, could lead to suspension, in-service trainings, counseling, or termination. Interview on 05/07/25 at 4:41 pm, the DON stated today (05/07/25) LVN A left a resident's medication on the medication cart unattended. She stated anyone could have passed by her med cart, and the residents or anyone could have taken them off of LVN A's med cart. She stated the nurses were responsible to ensure the medications administered were inside, and locked in the medication cart before they left their medication carts. Interview on 05/07/25 at 5:18 pm, Medical Records D stated if a resident's medications were left unattended on the med carts. She stated if she saw that she would stand next to the med cart until that nurse arrived back to it, then report it to the Administrator. She stated today (05/07/25) this morning she saw the medication cart on the 100 hall and saw LVN A coming out of a resident's room and walking to the medication cart. She stated she asked LVN A about getting a wheelchair for a resident and did not realize a resident's medication cards were on the med cart. She stated she saw the HHSC Surveyor standing on the other side of the med cart. She stated leaving medications unattended could cause someone to use the information on the medication card to open up another medication account. She stated the information on the medication cards could be used for personal benefit because the resident's name, date of birth, medication name and dosages were on them. Interview on 05/07/25 at 5:29 pm, the Administrator stated it was brought to her attention today (05/07/25) that LVN A was getting ready to give Resident #1 his medications and Resident #2 located across the hall needed assistance. She stated LVN A went to Resident #2's room and left Resident #1's medications on top of the med cart. She stated LVN A did not follow the facility's protocol because all medications needed to be secured at all times and locked in the med cart or being given to the resident. She stated today (05/07/25) they did an in-service training with all nursing staffing and medication aides. She stated they trained the staff not to leave medications on the medication carts and to put them in the med cart locked. She stated leaving medications out could lead to different things, a resident could get them or result in a drug diversion. She stated not leaving medications unattended on medication carts was nursing school 101 and LVN A knew because it could cause a breach in a resident's identity. She stated she and the DON spoke to LVN A by doing a 1 on 1 meeting with her to never leave medications on top of the med carts. She stated LVN A said while administering Resident #1's medications, she went to see about Resident #2 and repositioned her. She stated when she returned back to her med cart the HHSC state lady was standing right next to it. She stated LVN A said she was not all the way down the hall or in the dining room. Record review of LVN A's Counseling Disciplinary Notice dated unsigned by LVN A or nurse management revealed, LVN A's Date of hire: 05/29/24, date of notice: 05/07/25. Type of action being taken: Final written/warning*. 2. Reason (s) why counseling/disciplinary action is necessary, including a complete explanation of the conduct constituting the violation. If additional space is required please see attach a separate sheet. Employee is expected to keep medications secured in nurses cart at all times. No exceptions. Record review of the Facility's Training dated 05/07/25 with nine signatures including LVN A's signature revealed, Medication must be locked in cart when cart is left unattended. Only licensed nurses and Certified Medication Aides may have access to medication cart. Cart should be clean and organized. If nurses are to step away from cart for any reason, med must be stored and cart must be locked. Record review of the Facility's Resident Right policy amended 07/13/17 revealed, Privacy and confidentiality: Secure and confidential personal and medical records. Recorde of the Facility's Medication Access and Storage/Destruction policy dated 7/2023 revealed, Policy: It is the policy of this facility to store all drugs and biologicals in locked compartments under proper temperature controls. The medication supply is assessible only to licensed nursing personnel, pharmacy personnel, or staff member authorized to administer medications: Procedures Only licensed nurses, consutltant pharmacist and those lawfully authorized to administer medications (e.g. medication aides) are allowed access to medications, medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observations, interviews, and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 of 8 (Resident #16, Resident #61, and Resident #27) residents reviewed for call lights. 1. The facility failed to ensure Resident #16 had a call light device appropriate to her limited use of her hands. She was provided a button type call light when she was unable to bend her fingers. 2. The facility failed to ensure Resident #61 had a call light device appropriate to her limited use of her hands. She was provided a button type call light device when both her hands were contracted into fists. 3. The facility failed to ensure Resident #27's call button was within reach while Resident #27 was in her bed. Findings included: 1. Record review of Resident #16's Admission Record dated 2/9/25 reflected a [AGE] year-old female originally admitted to the facility on [DATE]. Record review of Resident #16's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 12 indicating moderately impaired cognition. Her diagnoses included stroke, aphasia (language disorder affecting speech); hemiparesis (muscle weakness or partial paralysis on one side); depression; gastrostomy (feeding tube); and muscle wasting and atrophy (loss of muscle mass and strength). She had limited range of motion in all limbs. She was usually understood and usually understood others. She was dependent on staff for all ADL s, was incontinent of bowel and bladder. Record review of Resident #16's Care plan reflected the following: At risk for falls r/t CVA with left sided weakness, incontinence, decreased mobility . Interventions included, Anticipate and meet needs.; Be sure the call light is within reach and encourage to use it to call for assistance as needed . Date initiated: 10/25/22. Has bowel/bladder incontinence r/t cognitive deficit secondary to history of CVA . Interventions included: Check as required for incontinence . Date initiated: 10/25/22. During an observation and interview on 2/9/25 at 9:21 AM Resident #16 was observed awake and sitting up in bed in her room. Her hands were observed to be extended in a flat manner. She had a button-type call light clipped to her blanket. Resident #16 stated she was unable to use that type of call light and stated she could not use her hands well since her stroke. She stated she was unable to bend her fingers in a way to press the button. She stated the staff were nice to her, but they were not in her room very often. During an observation on 2/9/25 at 12:20 PM, Resident #16 was observed in her room, sitting up in bed. She shook her head when greeted. She stated, I'm need help, I'm wet. She motioned with her hands and stated again that she was unable to use her call light. She asked this state surveyor to tell someone she was wet. There was a strong odor of urine and stool in the room. During an interview on 2/9/25 at 12:23 PM, the DON stated RN B was the charge nurse for Resident #16. She stated if a resident could not use their hands or could not talk, they should use the pad type of call light (round flat pad that activates with light touch ). During an observation and interview on 2/9/25 at 12:25 PM, RN B stated she had worked with Resident #16 and did not know if she had enough strength in her hands to use the push button type of call light. She stated the resident was able to use her TV remote by laying her hand on top of the remote to press the buttons. She stated, we check on her a lot and ask her if she needs to be changed, she'll let us know. She stated she would need to check with the DON to determine how residents were assessed for the call light type they needed. RN B was observed entering Resident #16's room and asked her if she needed to be changed and the resident nodded. RN B informed her she would be right back. CNA A entered the room carrying wipes. Incontinent care was provided by CNA A and RN B. CNA A stated Resident #16 was unable to use her call light, so staff checked on her a lot. 2. Record review of Resident #61's Admission Record dated 2/11/25 reflected an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #61's Quarterly MDS assessment dated [DATE] reflected she usually made herself understood and usually understood others, her vision was severely impaired, and she had moderate hearing difficulty. Her BIMS interview indicating cognitive level was not completed. She had limitations in both upper extremities. She was incontinent of bowel and bladder. Her diagnoses included non-Alzheimer's dementia; depression; muscle weakness; and cognitive communication deficit. Record review of Resident #61's BIMS assessment dated [DATE] reflected a score of 5 indicating severe cognitive impairment. Record review of Resident #61's Functional Performance Observation dated 2/6/25 reflected she was dependent on staff for eating, toileting, bathing, dressing, mobility, personal hygiene, and transfers. Record review of Resident #61's Care Plan reflected the following entries: At risk for communication problem r/t nonverbal. Interventions included: Anticipate and meet needs. Ensure/provide a safe environment: Call light within reach . Date initiated: 9/22/23. At risk for falls r/t new environment, dementia with Lupus [illness that occurs when the immune system attacks tissue and organs], Legal blindness. Interventions included: Be sure call light is within reach and encourage to use it to call for assistance as needed .Needs a safe environment .a working and reachable call light . Date initiated 9/15/23. During an observation on 2/9/25 at 9:27 AM, Resident #61 was observed in her room. Her bed was in a low position and a fall mat was on the floor alongside her bed. Her eyes were closed, and she did not respond to greeting. Her right hand appeared to be contracted and was in a fist. She had a button-type call light clipped to her blanket. During an observation and interview on 2/9/25 at 12:30 PM, Resident #61 was heard crying out. Both hands were observed clinched in fists. Her call light was clipped to her blanket near her hands. CNA A approached her and asked her what was wrong. When the resident continued to cry out, CNA A repositioned her and told her lunch was coming. Resident #61 calmed down and became quiet. CNA A stated Resident #61 was unable to use her call light. RN B was in the room and stated Resident #61 was unable to use her call light, so they checked on her often. She stated she was unsure whether the resident could utilize the pad type call light. She stated call light access was important because otherwise residents could not get help when needed and were at increased risk for falls. 3. Record review of Resident #27's Admission Record dated 2/9/25 reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #27's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 4 indicating severe cognitive impairment. She could make herself understood and understood others. She was dependent on staff for personal hygiene, dressing, and transfers. Her diagnoses included diabetes; seizure disorder; muscle weakness; dementia; and cognitive communication deficits. Record review of Resident #27's Care Plan reflected the following entries: Alteration in musculoskeletal status . Interventions included: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance . Date initiated 9/13/22. ADL self care performance deficit . Interventions included: Encourage to use bell to call for assistance . Date initiated 9/13/22. At risk for falls r/t dementia . Interventions included: .Be sure the call light is within reach and encourage to use it to call for assistance as needed . Date initiated 7/7/22. During an observation on 2/9/25 at 9:30 AM, Resident #27 was observed sleeping in her bed. Her call light was observed on the floor beyond the foot of her bed. During an observation on 2/9/25 at 12:48 PM, Resident #27 was observed in bed sleeping. Her call light was clipped to her blanket and within reach. CNA A was in the room and stated Resident #27 was able to use her call light and did not know why it was on the floor earlier. During an interview on 2/9/25 at 12:55 PM, the DON stated Resident #16 previously had a pad type call light and she did not know if someone had changed it out. She stated the ADON checked on her regularly. The DON stated Resident #61 used to be in a different room and had a pad type call light there and it was possible the device did not move with her when she changed rooms. She was unsure when the room change occurred. The DON stated management staff performed Angel rounds daily, Monday through Friday, and that was one of the things that should be checked. The DON stated she was unaware Resident #27's call light was not within her reach and staff should be checking them anytime they were in the rooms. She stated the risk for not having access to a call light was not receiving timely care. An observation on 2/9/25 at 12:59 PM revealed the ADON's name was posted outside Resident #16 and Resident #61's door on a sign that reflected, Angel indicating she was responsible for the rooms during Angel rounds. During an interview on 2/9/25 at 1:00 PM, the ADON stated she was responsible for conducting daily rounds in Resident #16 and Resident #61's rooms. She stated Resident #16 always had a pad type of call light but was unsure when she last saw it. She stated it may have been 3 weeks or so ago and she hadn't noticed it was changed. The ADON stated Resident #61 had moved from a room down the same hall and she believed the resident had a pad type call light in her previous room. She stated she had not noticed the button type was being used. She stated they established the appropriate type of call light to be used during their initial assessment when admitted and with any change of condition. She stated the nurses should let them know if a different type of device was needed and should ensure the call lights were in reach. The ADON stated risks for the inability of a resident to use a call light was falls, choking, and a delay in care. During an interview on 2/9/25 at 2:17 PM, the Administrator stated Resident #16 usually had the flat type of call light and she had seen her with it. She stated the resident would call out to them as well when she saw them in the hall. She did not know when the call device was changed. The Administrator stated Resident #61 was blind and did not use her call light. She stated she had moved from another room down the hall, and she was certain she had the pad type there. She stated Resident #61 was up during the day a lot and had frequent visits from her family. She stated Resident #27's call light should have been placed within reach and any staff should look for that when entering the room. She stated the risk of not having access to a call light was needs may not be met in a timely fashion. The Administrator stated the type of call device should be determined on initial assessments. She stated any concerns can be brought to daily stand-up meetings and be addressed immediately. She stated management staff conducted daily Angel rounds to catch issues in the rooms and the charge nurses were responsible for addressing the issues as well. Record review of the facility's policy titled, Accommodation of Needs dated Reviewed 08/2023 reflected: Policy: It is the policy of this facility to assure that a resident has a right to reside and receive services in the facility with reasonable accommodation of individual needs and preferences . Definitions: Reasonable accommodations of individual needs and preferences means the facility's efforts to individualize the resident's physical environment including: Resident's bathroom and bedroom . Procedures: 1. The facility will evaluate the resident's unique needs and make environmental accommodations to the extent reasonable 6. Have call light within reach.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchens reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's kitchen. These failures could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 02/09/25 beginning at 9:09 AM revealed unlabeled, undated, and uncovered food and beverage items: -3 trays of cups of dark liquid for a total of 18 cups of dark liquid; and -1 tray of cups of white liquid for a total of 11 cups of white liquid; and -3 trays with uncovered 12 slices of yellow cake on 3 trays for a total of 36 slices. Interview with the Dietary Manager on 2/10/25 at 11:30am revealed she reviews with staff ongoing about the importance of labeling and dating all food items including beverages and desserts. Dietary Manager revealed the importance of dating and labeling food to identify the food or beverage items along with to ensure the residents receive the correct food and beverages. Dietary Manager revealed she is responsible for ensuring dietary staff were storing food properly. She stated the beverages and food items were supposed to be dated and labeled. She stated improper food storage could cause harm to residents such as food borne illnesses. Interview with [NAME] A on 2/10/25 at 11:43am revealed labeling, dating, and covering beverages and food items are examples of food safety practices. [NAME] A revealed unlabeled, undated, and uncovered food could become contaminated and make the residents sick. Interview with Dietitian on 2/11/25 at 9:23am revealed unlabeled, undated, and uncovered food and beverage items could lead to food borne illness. Record review of the facility policy titled Infection Control Policy/Procedure Dietary Services, dated as revised 05/2007, revealed the policy statement, It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness. Procedure revealed 1. Director of Food Service Responsibilities A. Provide safe food services for residents and employes. Under the Proper Food Handling section, letter K revealed Leftovers must be dated, labeled, covered, cooled and stored (within 1/2 hour) in refrigerator, not at room temperature. The Food and Drug Administration Food Code dated 2017 reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 (Resident #34, Resident #16 and Resident #36) residents reviewed for infection control. 1. CNA A failed to perform hand hygiene while performing incontinent care for Resident #34. 2. CNA A failed to perform hand hygiene while performing incontinent care for Resident #16. 3. CNA E failed to perform hand hygiene while performing incontinent care for Resident #36. These failures could place residents at risk for infection through cross contamination of pathogens. Findings included: 1. Record review of Resident #34's Admission Record dated 2/9/25 reflected a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #34's Quarterly MDS assessment dated [DATE] reflected her BIMS assessment was not completed. She had functional limitation to both upper and lower extremities. She was dependent on staff for toileting, bathing, dressing, transfers, and personal hygiene. She was incontinent of bowel and bladder. Her diagnoses included kidney failure; septicemia (life-threatening infection that spread to bloodstream); acute cystitis with hematuria (bladder infection with blood in the urine); and quadriplegia (partial or complete paralysis up upper and lower limbs). She received dialysis. Record review of Resident #34's BIMS assessment dated [DATE] reflected a score of 14 which indicated she was cognitively intact. Record review of Resident #34's Care Plan reflected the following entry: Has bowel/bladder incontinence. Interventions included: Monitor/document for s/sx UTI : pain, burning, blood-tinged urine, deepening of urine color, increased pulse, increased temp . Date initiated 11/7/22. During an observation and interview on 2/9/25 at 10:05 AM, Resident #34 was awake and sitting up in bed. She stated the staff were coming soon to get her up to her chair because she slept in that morning. CNA A arrived, sanitized her hands, and gathered items needed for incontinent care. She donned gloves, lowered the resident's brief, and cleaned her perineal area appropriately. CNA A assisted Resident #34 to turn onto her side and cleaned her buttocks. The resident's skin was intact. CNA A then removed the soiled brief and placed a clean one without changing her gloves. She placed the soiled brief and wipes into the trash, removed her gloves, and sanitized her hands. She proceeded to assist Resident #34 with selecting items to wear. 2. Record review of Resident #16's Admission Record dated 2/9/25 reflected a [AGE] year-old female originally admitted to the facility on [DATE]. Record review of Resident #16's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 12 indicating moderately impaired cognition. Her diagnoses included stroke, aphasia (language disorder affecting speech); hemiparesis (muscle weakness or partial paralysis on one side); depression; gastrostomy (feeding tube); and muscle wasting and atrophy (loss of muscle mass and strength). She had limited range of motion in all limbs. She was usually understood and usually understood others. She was dependent on staff for all ADLs, was incontinent of bowel and bladder. Record review of Resident #16's Care plan reflected the following: Has bowel/bladder incontinence r/t cognitive deficit secondary to history of CVA . Interventions included: Check as required for incontinence. Wash, rinse, and dry perineum . Monitor/document for s/sx UTI: pain, burning, blood-tinged urine, deepening of urine color, increased pulse, increased temp . Date initiated 10/25/22. During an observation and interview on 2/9/25 at 12:25 PM, RN B was observed entering Resident #16's room and asked her if she needed to be changed and the resident nodded. RN B informed her she would be right back. CNA A entered the room carrying wipes. She washed her hands and donned a gown and gloves. She began incontinent care by cleaning Resident #16's perineal area from front to back. She assisted the resident to turn onto her left side and continued cleaning her. Resident #16 was observed to have had a large watery bowel movement, some of which was observed on the pad beneath her. CNA A removed the soiled brief and pad then placed a fresh brief beneath the resident without removing her gloves. Resident #16 began to have another bowel movement and CNA A told her she would give her a few minutes to let her finish. She bagged the soiled brief and pad and reached for a fresh brief while wearing the same gloves. RN B entered the room, washed her hands, donned a gown and gloves, and moved to the opposite side of the bed to assist the CNA. Resident #16 stated she thought she was finished, and CNA A began cleaning her again then replaced the soiled brief with a clean one. She placed a fresh pad beneath the resident and bagged the soiled brief and wipes, removed her gloves, sanitized her hands, and replaced her gloves. CNA A and RN B positioned Resident #16 for comfort. CNA A doffed her gown and gloves and washed her hands. CNA A stated she should change her gloves and sanitize her hands before and after providing care. When asked whether she should have changed her gloves between handling dirty and clean pads and briefs, she replied, No, I think I should have, it makes sense. She stated the risk of handling clean items with soiled gloves was the spread of infection. RN B stated they should change gloves and sanitize hands between handling dirty and clean items to prevent cross contamination. She stated she had not noticed that CNA A was using the same gloves. 3. Review of Resident #36's Face Sheet, dated 02/11/25, reflected she was a [AGE] year-old female, who initially admitted to the facility on [DATE], with diagnoses including major depressive disorder (a mental health condition that can cause persistent feelings of sadness and hopelessness) and anxiety disorder (a mental health condition that involves excessive fear, worry, or dread). Review of Resident #36's MDS Assessment, dated 12/28/24, reflected she was always incontinent of bladder and bowel. Review of Resident #36's Care Plan, initiated on 01/31/24, reflected she was incontinent of bladder and bowel. Her care plan reflected she required the use of briefs and staff assistance for incontinent care. Observation from the hallway on 02/09/25 at 9:55AM revealed Resident #36's door was open as CNA E was providing incontinent care. On 02/09/25 at 9:59AM, CNA E was observed to bring a bag of used incontinence supplies out of the room and throw it away. She then went through the clean linen cart to gather fresh linens. At no point after providing incontinent care did CNA E use hand washing or hand hygiene prior to accessing the linen cart. During an interview with CNA E on 02/09/25 at 10:07AM, she stated she normally performed hand washing and/or hand hygiene after completing incontinent care. She did not think to do so with Resident #36 because she was trying to get her assigned tasks completed. She stated the risk of not performing hand washing and/or hand hygiene was that infection could spread. During an interview with the Director of Nursing on 02/09/25 at 1:38PM, she stated the expectation was for the facility staff providing incontinent care to perform hand hygiene before starting care, when changing gloves (such as when the gloves were dirty), and after care (including after discarding supplies). The Director of Nursing stated the risk of not completing proper hand hygiene/hand washing was the spread of infection. Record review of the facility policy titled, Hand Washing, dated reviewed 07/2014 reflected: Policy: It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff. Purpose: Hand washing/ hand hygiene is generally considered the most important single procedure for preventing the transmission of infection. Antiseptics control or kill microorganisms contaminating skin and other superficial tissues and are sometimes composed of the same chemicals that are used for disinfection of inanimate objects . Except for situations where hand washing is specifically required, antimicrobial agents such as alcohol-based hand rubs are also appropriate for cleaning hands and can be used for direct care . For specific handwashing and waterless hand hygiene procedures, this facility refers to CDC's most current guidelines. Review of the CDC website on 2/11/25 reflected https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, Clinical Safety: Hand Hygiene for Healthcare Workers .Know when to wear and change gloves . When to wear gloves. When needed for Standard Precautions (when you anticipate that you will come in contact with blood or other infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment) When to change gloves and clean hands . If gloves become damaged; If gloves become soiled with blood or body fluids after a task; If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs; If moving from care on one patient to another patient. If they look dirty or have blood or body fluids on them after completing a task; Before exiting a patient room. 35747

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases for five (LVN A, Medical Records Staff B, OTA C, OTA D, and OT E) out of ten staff reviewed for infection control practices and transmission-based precautions. 1. The facility failed to ensure LVN A wore an N95, or equivalent, mask over her mouth and nose at all times when in quarantined rooms with residents positive for COVID-19, including while suctioning a COVID-19 positive resident, according to the facility's policy. 2. The facility failed to ensure LVN A and Medical Records Staff B utilized PPE appropriately to prevent cross contamination at all times when in quarantined rooms with residents positive for COVID-19, according to the facility's policy. 3. The facility failed to ensure OTA C, OTA D and OT E wore a mask over their noses and mouths at all times when they were around residents, according to the facility's policy. An IJ was identified on 11/29/23. The IJ template was provided to the facility on [DATE] at 2:50 PM. While the IJ was removed on 11/29/23, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because all staff had not been trained on infection control and prevention. These failures placed residents at risk of exposure of COVID-19 virus which could result in serious illness, hospitalization , and/or death. Findings included: Observation of the facility's posted sign at the receptionist desk, dated 11/29/23, advised that masks were mandatory in the building. Record review of the facility's undated, untitled document stated Resident #1, Resident #2, Resident #3, and Resident #4 all tested positive for COVID-19 on 11/29/23. It also revealed Receptionist tested positive for COVID-19 on 11/2923. Record review of Resident #1's face sheet, dated 11/29/23, revealed a [AGE] year-old female, with a diagnoses of Schizophrenia (delusions and hallucinations), Asthma (chest tightness and breathing issues), Type 2 Diabetes (condition that affects the way the body processes sugar), Dementia (impaired ability to remember), and hyperlipidemia (high levels of fat in the blood). Record review of Resident #2's face sheet, dated 11/29/23, revealed an [AGE] year-old female, with a diagnoses of Asthma (chest tightness and breathing issues), Constipation (less frequent or no bowel movements), Heart Failure, Hypertension (high blood pressure), Dysphagia (difficulty swallowing), Metabolic Encephalopathy (brain issues caused by chemical imbalance), Type 2 Diabetes (condition that affects the way the body processes sugar), and Hyperlipidemia (high levels of fat in the blood). Observation and interview on 11/29/23 at 12:19 PM, revealed LVN A prepared to go into a quarantined room with Resident #1 and Resident #2, who were both positive for COVID-19. LVN A put on a gown and gloves. LVN A did not tie the gown around her body, and she did not put on a face shield. LVN A was observed as she entered the quarantined room with a surgical mask, which did not cover her nose. LVN A's nose was exposed while she was in the quarantined room with Resident #1 and Resident #2. LVN A was observed as she took Resident #2's vital signs. LVN A stated that Resident #2 needed oxygen, so LVN A disposed of her gown and gloves in the bathroom area of the quarantined room, washed her hands, then walked out of the room still wearing her surgical mask below her nose. LVN A was observed as she left the hot area (area where COVID-19 positive residents are housed) and into the main area near the main nurse's station and past a resident in a wheelchair. LVN A retrieved an oxygen tank and walked back passed the resident in the wheelchair and staff members at the nurse's station, back to the hot area. LVN A was observed as she put on a gown and gloves and returned to the quarantined room with her nose exposed from the surgical mask. Medical Records Staff B came to assist LVN A. Medical Records Staff B stated she was not a nurse, but she helped staff when they needed assistance. LVN A was observed as she walked toward the door of the quarantined room and passed a blood pressure wrist cuff to Medical Records Staff B. LVN A asked Medical Records Staff B to record the vitals that were on the blood pressure cuff. Medical Records Staff B took the blood pressure wrist cuff with no gloves on, sanitized the blood pressure cuff with a germicidal wipe, and did not sanitize her hands. Medical Records Staff B was later observed going into the quarantined room to assist LVN A. Medical Records Staff B was observed putting on a gown, gloves, as she entered the quarantined room. Medical Records Staff B had on an N95 mask, but the bottom strap was hanging below her chin. Medical Records Staff B was then observed she discarded her gown and gloves into the trash in the bathroom, which is where the staff stated they washed their hands, and left the quarantined room as she still wore the same N95 mask. Medical Records Staff B was observed as she walked back into the general area near the main nurse's station. LVN A was then observed stood in the doorway of the quarantined room. She spoke with Medical Records Staff B and DON. LVN A advised that she thought Resident #2 needed to go to the hospital. LVN A was observed as she went back into the quarantined room with the surgical mask pulled below her chin, not covering her nose or mouth. LVN A was observed as she pulled her cellphone out to call 911, while standing next to the COVID-19 positive resident. LVN A was also observed suctioning the mouth of the COVID-19 positive resident while wearing her surgical mask inappropriately. LVN A was observed discarding her gown and gloves into the bathroom, and as she came out the room. LVN A did not wash her hands or sanitize, before returning to her cart to put on lotion. LVN A was then observed as she returned to the quarantined room, to the bathroom, to wash her hands, with no PPE on. LVN A stated she was not only working in the 400, hot hall, but also working in the 200 hall during her shift. She stated she had been trained on how to properly wear her surgical mask to cover her nose and mouth. She stated she knew she should have had on the N95 mask when providing care to the COVID-19 positive residents. LVN A stated she felt it was an emergency and stated she knew the risks. She stated the risks of not wearing full PPE or her PPE correctly was passing COVID-19. In an interview on 11/29/23 at 12:51 PM, DON stated Resident #2 was not feeling well this morning, so that prompted them to test her for COVID-19. DON stated Resident #2 was normally up and in the dining hall, went to therapy, was in the resident council, and was usually all over the building. She stated they tested all residents and all staff. She stated there were four positive residents, and Receptionist was positive for COVID-19. She stated Receptionist was sent home to quarantine. Operations Manager stated the current policy was surgical masks in the general facility and with residents not positive with COVID-19, and N95 masks in the quarantined areas, around the positive residents. Operations Manager stated they notified their medical director and the local ombudsman this morning after the testing was completed. She stated they were in the process of doing a self-report to the state. DON stated they stated in-servicing the staff on PPE donning and doffing, current mask requirements, hand-washing, and overall infection control. DON stated LVN A and Medical Records Staff B should have worn all PPE or should have worn it correctly. In an interview on 11/29/23 at 1:20 PM, Medical Records Staff B stated a majority of the time she would assist the nurses, because she knew were all the supplies were in the building. She stated she was trained on how to properly wear a mask. She stated usually she would ensure she wore gloves, gown, mask, face shield, and shoe covers if they had shoe covers out in the quarantined areas. She stated she knew to discard the PPE before she left the quarantined area, and to wash her hands as well before she left the area. Medical Records Staff B stated she did not realize the bottom strap of her N95 mask was hanging under her chin. She stated she did not have a particular reason why she wore her mask with the strap hanging under her chin. Medical Records Staff B stated she did recall that she stepped into the quarantined room at one point with no gown on and stated she knew better. She stated she had not helped any other staff or residents prior to when she assisted LVN A. She stated the facility has plenty of PPE, and she had masks on her desk. She stated she did not think about moving her mask from her face when she left the quarantined area. Medical Records Staff B stated the Operations Manager had just mentioned to her that she should remove her N95 mask when she left the quarantined area. She stated she just took more N95 masks to the quarantined area. She stated the facility has a supply of face shields too, but she doe does not know why they were not available in the quarantined bins, or why she or LVN A did not wear a face shield. She stated the nurses were usually responsible for filling the quarantined bins, but the med techs and caregivers could do it as well. Medical Records Staff B stated the risk of her not wearing her N95 properly and not removing it when she left the quarantined area was a risk of passing COVID-19 to others or getting COVID-19 herself. Observation on 11/29/23 at 11:40 AM, revealed OTA C, OTA D, and OT E in the therapy gym, all not wearing a mask that covered their nose or mouths. There were 11 residents observed in the gym, and at least three within six feet of the three staff members. In an interview on 11/29/23 at 1:36 PM, OTA C stated she was finishing a shake at the time, and knew she was in close proximity to residents. She stated she was not sure if the staff were permitted to eat or drink around residents when COVID-19 was present in the building. She stated in the past she usually would not eat or drink in the room with residents when COVID-19 was in the building. OTA C stated the staff were informed at the beginning of their shift, around 8AM, that residents had tested positive for COVID-19, and the staff were told to wear masks. She stated the facility trained the staff on how to properly wear a mask, which was to go over your nose and to properly fit around your face. OTA C stated she knew the risk of not wearing a mask or wearing it properly was exposure to COVID-19. In an interview on 11/29/23 at 2:00 PM, OTA D stated he took his mask off in the gym, because he had trouble breathing. He stated he was aware there were residents in the room and behind him. He stated he was told today to start wearing masks again. He stated he was informed that if he was working with a COVID-19 positive residents, to wear an N95 mask, and if he was in the general area with residents, to wear a surgical mask. He stated he was told he had to wear full PPE if he went on the COVID-19 hall. OTA D stated he had COVID-19 at the beginning of this month, November 2023. He stated the proper way to wear a mask is to cover your nose and mouth and press it down to ensure it's sealed. He stated the risk of not wearing a mask or wearing it properly was he could get COVID-19 or give it to a patient. In an interview on 11/29/23 at 2:25 PM, OT E stated the facility trained her on the proper way to wear PPE. She stated the proper way to wear a mask was to ensure it covered your nose, ensure you could not feel any air around it, and to ensure it was properly fitted around your ears. She stated today the staff were advised to wear masks. OT E stated she was claustrophobic, so if she was not in direct contact with a resident, she did not wear her mask. She stated if she was around a resident that is positive for COVID-19, she would wear an N95, but if the resident was not positive, she would wear a surgical mask. She stated she was aware her nose was exposed. OT E stated the risk of not wearing your mask or not wearing it properly was to catch COVID-19 or give it to the next person. Record review of the facility's undated policy titled, Emerging Infectious Disease: Coronavirus Disease 2019 (COVID-19), revealed the following: It is the policy of this facility implement recommended appropriate infection control strategies, guidance and standards from the local, state and federal agencies, for an EID event. It is further the policy to include preparatory plans and actions to respond to the threat of the COVID-19, including but not limited to infection prevention and control practices in order to prevent transmission. Infection Prevention and Control for EID: Personal Protective Equipment and Supply: PPE may include facemasks, N-95 or higher-level respirators, gowns, gloves, and eye protection (i.e. face shield or goggles) Managing Residents with Suspected or Confirmed SARS-CoV-2 Infection Residents with suspected or confirmed SARS-CoV-2 do not need to be placed in an airborne infection isolation room but should be cared for using an N95 or higher-level respirator, eye protection (i.e. goggles or a face shield that covers the front and sides of the face.), gloves, and gown. Record review of the facilities posted sign, dated 11/29/23, advised that masks were mandatory in the building. The same sign was posted at the receptionist desk. Record review of the facilities In-Service, dated 11/29/23, and titled In-service Training Report, revealed the following: Department: Therapy Topic: Masks, Infection Control, Hand-washing Contents or summary of training: Masks need to be worn at all times over nose and mouth. Handwashing between residents must be performed. Staff cannot eat/drink with residents in the gym. Staff must utilize breakroom on 300 hall. The Administrator was notified on 11/29/23 at 2:35 PM that an Immediate Jeopardy was identified due to the above failures. The Administrator was provided the IJ template on 11/29/23 at 2:50 PM. The facility's plan of removal was accepted on 11/29/23 at 5:19 PM and included the following: [Facility Name] Plan of Removal Version 2 F880 Infection Control Per the information provided in the IJ Template given on 11/29/23, the facility failed to ensure all staff properly donned and doffed PPE when leaving and entering the COVID rooms. Currently there are 3 COVID rooms. Immediate Action 1. The Medical Director was notified of IJ on 11/29/23 at 3:00pm. 2. LVN, Medical Records Clerk, and Therapy Staff observed by surveyor were in-serviced immediately. The DON and Cluster Partner in-serviced these staff on masking, donning/doffing PPE, outbreak procedures, and handwashing. 3. Training and competency on donning and doffing PPE, handwashing, and outbreak procedures will be completed with all staff. This training was initiated on 11/29/2023 and will be completed by 11 / 30/ 2023. The training includes masking, donning/doffing PPE, procedures for outbreak and hand washing and will be provided by the DON, ADON, Clinical Resources, Cluster Partners, Rehab Director, and Operations Manager. Train the trainer in-service was given by the Clinical Resource and was completed with DON, ADONs, Cluster Partner, Rehab Director and Operations Manager. 4. This training will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all get trained prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for agency/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and competency. 5. An ad hoc meeting regarding items in the IJ template will be completed on 11/29/2023. Attendees will include the DON, Medical Director, Infection Preventionist/ADON, Clinical Resource, Ops Manager, Clinical Resources and will include the plan of removal items and interventions. 6. The DON, ADON or Clinical Resource will verify staff competency with 10 staff weekly using the PPE and handwashing competency checklists. This will be completed weekly after the initial training and competency began on 11/29/23 and are completed by 11/30/2023. 7. COVID positive residents will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to the DON, ADON, Rehab Director and Ops Manager. The DON and Ops Manager will be responsible for ensuring this meeting is held weekly and COVID positive residents are reviewed. This meeting will begin 11/29/2023. 8. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring: In an interview on 11/29/23 at 5:24 PM, Med Tech F stated she was told there was positive COVID-19 residents when she entered the facility for her shift this morning. She stated the receptionist told her to wear a mask. Med Tech F stated she was provided an N95 mask and was told to wear it for the entire shift. She stated she received an in-service over COVID-19, infection control, how to properly wear a mask, and received a COVID-19 test when she arrived. She stated the facility had enough PPE supplies. In an interview on 11/29/23 at 5:31 PM, Nurse G stated the facility had a good supply of PPE. Nurse G stated she was in-serviced today, when she arrived at 2 PM. She stated the in-service was over PPE, how to properly wear masks, handwashing, infection control, and COVID-19. In an observation on 11/29/23 at 5: 45 PM, Nurse G was observed as she donned gloves, gown, N95 mask, and face shield before she entered the quarantined room. She was observed as she assisted Resident #3. She was observed as she doffed all PPE, washed her hands, and exited the quarantined room. Nurse G was observed as she sanitized her hands after leaving the quarantined room and observed as she put on another mask. In an interview on 11/29/23 at 5:54 PM, Med Tech H stated the facility had plenty of PPE supplies. She stated the facility informed her today some residents tested positive for COVID-19, early this morning before or around 8 AM. She stated the staff were told to wear N95 masks. She stated they were told to wear N95 masks if they went into the COVID-19 rooms, and they could wear surgical masks if they were not in that area or around positive residents. She stated she received a COVID-19 test this morning, and it was negative. She stated she was in-serviced today on infection control, COVID-19, PPE donning and doffing, which PPE to wear around COVID-19 positive residents, which was masks, gloves, gown, face shield, and shoe covers if they had them. She stated she was trained on how to properly wear a mask, which was the mask was supposed to cover your nose and mouth. In an interview on 11/29/23 at 6:01 PM, ADON stated she had been the ADON and facility preventionist for 13 days. She stated she was one of the facilitators for the in-services completed today. She stated DON in-serviced her on infection control, donning and doffing PPE, COVID-19, handwashing, and how to properly wear a mask. She stated all positive residents would be moved to the COVID-19 hall. She stated they did not have dedicated staff for the COVID-19 positive residents, because there was a small amount of positive residents. She stated the staff cared for non-positive residents as well. ADON stated the facility will do follow-up COVID-19 tests on residents and staff on day 3 and day 5. She stated if people still tested positive for COVID-19, then the cycle would start over again. ADON stated the risk of not wearing the PPE appropriately would be infection control, staff could he get COVID-19, then the residents, or vice versa. She stated different residents had different health issues and catching COVID-19 could make those residents worse. In an interview on 11/29/23 at 6:15 PM, DON stated she had been DON since September 2023. She stated the facility in-serviced the staff that were present today. She stated she was in-serviced by the Clinical Resources Director. She stated the in-service went over donning and doffing PPE, masks, handwashing, N95 masks which should be worn around positive residents/surgical masks for the other residents, and infection control in general. DON stated the residents and one staff member just tested positive for COVID-19 today. She stated they did not have dedicated staff for the COVID-19 hall. DON stated the facility went over the risks during the in-service, and the main risk was getting COVID-19. DON stated you do not want to get infected or infect someone else. In an interview on 11/29/23 at 6:19 PM, Operations Manager stated she had been the Operations Manager since July 2023. She stated the facility's Administrator, was out on leave, and she covered his position. She stated in-services were completed on staff today, and she was in-serviced by DON. She stated the in-service covered donning and doffing PPE, how to properly wear a mask, hand hygiene, COVID-19, and infection control and prevention. She stated the facility's policy is to test staff and residents on day 1, 3, and 5. She stated all staff should keep masks on for 14 days. She stated if the facility had no positive cases on day 14, then on day 15 the mask requirement would be removed. Operations Manager stated if there were still positive cases on day 14, then the mask requirement would be extended another 14 days. She stated the risk of not wearing PPE appropriately was exposure to COVID-19. Record review on 11/29/23 of the following: In-Service dated 11/29/23, titled, In-service Training Report, and Subject was Infection Control, PPE, Masking, Outbreak, Testing. In-Service dated 11/29/23, titled, In-service Training Report, and Subject was, Donning/Doffing PPE. In-Service dated 11/29/23, titled, In-service Training Report, and Subject was, COVID-19 Positive/Symptoms, Resident and Staff Handwashing. Record review of COVID-19 Vaccination verification for Receptionist, LVN A, Medical Records Staff B, Resident #3, Resident #1, Resident #2, and Resident #4. All had received two COVID-19 vaccinations. Record review of Suspension document and in-service for LVN A, dated 11/29/23 On 11/29/23, Operations Manager was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status and a need to alter treatment significantly for one (Resident #1) of 5 resident reviewed for changes in condition. The facility failed to notify the physician when the resident began having seizures and required hospitalization s on 12/03/22, 12/04/22 through 12/08/22, and 12/12/22 through 12/23/22 as evidence of the failure to monitor diagnostic lab work and to follow the pharmacy's recommendation to obtain orders for lab levels. This failure resulted in identification of Immediate Jeopardy (IJ) on 1/20/2023 at 4:40 p.m. The IJ was removed on 1/21/2023 at 3:50 P.M. While the IJ was removed on 01/21/23, the facility remained out of compliance at a scope of a pattern and actual harm with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for not receiving adequate care and treatment, hospitalization s, and possible death. Findings included: Record review of Resident #1's Face Sheet dated 1/19/2023 indicated she was a [AGE] year-old female admitted to the facility on [DATE], with a recent readmitted [DATE]. Resident #1's diagnoses included, unspecified convulsions, status epilepticus (seizure that lasts too long or when seizures occur close together and the person doesn't recover between seizures), diabetes, muscle weakness, reduced mobility, high blood pressure, heart disease, arthritis, and anemia (lack of enough healthy red blood cells to carry adequate oxygen to body's tissues). Record review of Resident #1's MDS dated [DATE] reflected a reentry date of 12/23/2022 from an acute (sudden) hospital stay. The MDS noted the date the episode for transfer to hospital began was on 12/08/2022. Resident #1's BIMS score was an 11 , which indicated moderate cognitive impairment per brief interview for mental status. Resident #1 required extensive physical assist with bed mobility, transfer between surfaces, dressing, toilet use, personal hygiene, locomotion on and off the unit using a wheelchair as a mobility device and only able to stabilize with staff assistance. Resident #1 had no behavioral symptoms during the MDS review period. Record review of Resident #1's Care Plan dated 12/28/2022 indicated she had a seizure disorder, and the goal was to help her remain free from injury related to seizure activity and reflected an additional goal to maintain lab values within a therapeutic range. Resident #1's care planned interventions indicated the following: -give the medications as ordered. Monitor and document for effectiveness and side effects. -monitor labs and report any sub therapeutic or toxic results to the MD. -obtain and monitor lab/diagnostic work as ordered. Report results to the MD as follow up as indicated. Interview on 1/19/23 at 10:00 am with Resident #1's family member, she said Resident #1 had not had any seizures for many years, and said she recently had three visits to the hospital in December 2022 after having seizures. She thinks the cause for the re occurrences of the seizures is due to facility nurses not giving Resident #1's antiseizure medications correctly and the resident told her the nurses were not giving her the medications as prescribed and skipping giving her doses. Resident #1's family member said that she was told by MDs at the hospital that the cause for the new onset seizure activity may have been due to labs not being drawn in a constant manner, and the medication not being provided as prescribed. Resident #1's family member said she was also told by the hospital MD's Resident #1's antiseizure medication levels were low and that is why she was having seizure, and that is the reason Resident #1's family member called the State Health and Human services to complain about the resident's care, and to have someone come out and investigate the facility. Interview on 1/19/23 at 10:15 am with Resident #1, the resident was in bed and revealed she was upset for the last three visits to the hospital emergency room because she started having seizure again. Resident #1 was teary and gloomy, saying she had lived in the facility for about [AGE] years and for many of those years she had not experienced seizures. Resident #1 said that maybe the seizures began because the nursing staff would take long bringing her morning and evening medications, and said she thought they did not give her some of the doses. Review of Resident #1's Clinical Physician's Orders, dated 12/01/2022 reflected the resident had orders for antiseizure medications as follows: -Carbamazepine tablet 200 mg, give 1 tablet by mouth before meals for seizures, order date was 6/29/2022 -Dilantin capsule, five 200 mg, give by mouth two times as day related to epilepsy, order date was 6/29/2022 -Levetiracetam tablet 1000 mg, give 1 tablet by mouth two times a day for seizures related to epilepsy, order date was 7/06/2022. -Resident #1's Clinical Physician Orders did not include instructions for antiseizure medication lab draws. Record review of Resident #1's Consultant Pharmacist's Medication Regimen Review document dated 7/01/2022 through 7/18/2022 reflected a pharmacist's recommendation to check Dilantin and Carbamazepine blood levels, suggested to ensure lab result levels were current in Resident #1's electronic medical record for review for AED medications Dilantin and Carbamazepine, the suggestion was signed off by the DON, she signed off by adding a notation completed. Record review of Resident #1's Consultant Pharmacist's Medication Regimen Review document dated 10/01/2022 through 10/17/2022 reflected a pharmacist's recommendation to check Dilantin and Carbamazepine blood levels, suggested to ensure lab result levels were current in Resident #1's electronic medical record for review for AED medications Dilantin and Carbamazepine, the suggestion was signed off by the DON. Record review of Resident #1's Consultant Pharmacist's Medication Regimen Review document dated 12/01/2022 through 12/12/2022 reflected a pharmacist's recommendation to check Dilantin and Carbamazepine blood levels, suggested to ensure lab result levels were current in Resident #1's electronic medical record for review for AED medications Dilantin and Carbamazepine, the suggestion was signed off by the DON and she added the labs were ordered but Resident #1 had been sent to the hospital. Record review of Resident #1s Progress Note written by ADON I dated 12/03/2022 at reflected Resident #1 was in bed and ADON I documented an observation of the resident having some confusion, complaining of headache, and did not note the resident having a seizure. ADON I documented Resident #1 stated she felt like she was going to have a seizure and called 911 per Resident #1's request. The note reflected the resident was transferred to the emergency room , and ADON I called and notified the NP. Record review of Resident #1's emergency room stay on 12/03/2022 reflected she was discharged back to the nursing facility on 12/03/22with seizure discharge instructions and to follow up with the hospital in 3 days if symptoms worsened. The record reflected for Resident #1 to follow up with a neurologist in 1 week, the name, phone number and address were provided on the discharge paperwork, and according to DON the neurologist appointment was not made because of Resident #1 until 12/27/22 due to Resident #1's numerous hospitalization s. The record reflected the reason for the emergency department visit was due to seizures. Record review of Resident #1's emergency room admission record dated 12/03/2022 titled Lab Tests Completed reflected in part some of the lab's levels that were during the visit included, Carbamazepine and Phenytoin. Record review of Resident #1's emergency room admission record dated 12/03/2022 titled Lab Results reflected Carbamazepine blood level final result was abnormal, it was 3.2, (*normal reference range is 4.0 - 12.0 ug/mL *) and Phenytoin level at 6.0 (*normal reference range is 10.2 - 20.0 ug/mL). Record review of Resident #1's emergency room admission record dated 12/03/2022 titled Medications given reflected the resident received AED medications and none of the doses had been changed. Record review of Resident #1's emergency room discharge instructions dated 12/03/2022 reflected there were no upcoming doctor appointments scheduled, and to continue with the same medication regimen she was currently taking at the NH. During an interview on 1/19/2023 at 12:48 p.m. with ADON I, she said Resident #1 came back after midnight on 12/4/2022. ADON I stated the NP had ordered AED labs to be drawn on 12/04/22 but had not been drawn due to Resident #1's request to be sent back to the emergency department on 12/04/22. ADON I denied knowing the recommendations by the pharmacy consultant for therapeutic lab values were drawn prior to the emergency room visit and said and said she had not reviewed the hospital discharge instructions and when a resident was readmitted to the facility after a hospital stay it was the nursing administration teams responsibility to go over the records and implement any appointments or new orders. Record review of Resident #1s Progress Note written by ADON I and dated 12/04/2022 reflected Resident #1's family member told her she wanted Resident #1 to be sent out to the hospital be reassessed for seizures. ADON I wrote she observed Resident #1 in her room having a seizure lasting about 60 seconds, and when the seizure became less intense and ended, the patient returned to normal. ADON I called EMS who came to transfer Resident #1 to the hospital, and ADON I documented that the resident was observed to continue being disoriented on exit. During an interview on 1/19/2023 at 1:35 p.m. with ADON I, she said Resident #1's family member was in the room dressing her on 12/03/22 when the family member called out to say Resident #1 got hot and began perspiring,, the ADON I came into the room, and Resident #1 had calmed down, but the resident was looking at the ADON with a blank stare and not moving. ADON I said she thought Resident #1 was having a seizure, and she said, Once she came out of it, she was confused and called 911 for transport to the hospital. ADON I said Resident #1's family member told her Resident #1 had not had a seizure for [AGE] years. The ADON stated the recent seizure activity was out of the norm for Resident #1. ADON I said she notified the resident's NP regarding the hospital transfer. Record review of Resident #1's emergency room admission record dated 12/04/2022 titled ED Provider Note, Date of Service 12/04/2022, Chief Complaint reflected the patient presented to the emergency room with altered mental status problems and weakness. The physician stated Resident #1 had symptoms of altered mental status and questioned whether it was related to a seizure, noted the resident was taking Keppra, Dilantin, Tegretol, and stated an emergency medical clinician had witnessed the resident had a seizure while in route to the hospital from the nursing home and had been given versed (an anticonvulsant medication) which helped to stop the seizures. The ED physician also noted Resident #1 had been seen at another hospital on 12/03/2022 for a seizure. Record review of Resident #1's emergency room admission record dated 12/04/2022 titled ED Provider Note, Date of Service 12/04/2022, Chief Complaint reflected the patient presented to the emergency room with altered mental status problems and weakness. The physician stated Resident #1 had symptoms of altered mental status and questioned whether it was related to a seizure, noted the resident was taking Keppra, Dilantin, Tegretol, and stated an emergency medical clinician had witnessed the resident had a seizure while in route to the hospital from the nursing home and had been given versed (an anticonvulsant medication) which helped to stop the seizures. The ED physician also noted Resident #1 had been seen at another hospital on 12/03/2022 for a seizure. Record review of Resident #1's emergency room admission record dated 12/04/2022 titled Physical Exam Review of Systems (review of systems is an inventory of the body systems that is obtained through a series of questions in order to identify signs and/or symptoms which the patient may be experiencing) referenced Resident #1 was unable to be reviewed because she had a mental status change that prevented her from answering medical questions. Record review of Resident #1's emergency department to hospital admission record dated 12/04/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Phenytoin Level, Total - Abnormal; Notable for the following components: Phenytoin 6.7 (*normal reference range is 10.2 - 20.0 ug/mL). Record review of Resident #1's emergency department to hospital admission record dated 12/04/2022 titled Final Diagnoses reflected an admission diagnose of altered mental status, and stated, Patient left with a disposition of Admit. Record review of Resident #1's hospital admission record dated 12/05/2022 titled Hospital Medicine Admission History and Physical: Resident #1 reflected a chief complaint of altered mental status and weakness symptoms, and review of systems were noted to have lack of energy, headache, and confusion. Record review of Resident #1's hospital admission record dated 12/05/2022 titled Assessment & Plan Active Problems: # Seizure disorder, Continue Keppra 1000 mg BID, Phenytoin 200 mg BID, Carbamazepine 200 mg TID, Neurology referral on discharge. Record review of Resident #1's hospital admission record dated 12/05/2022 titled Neurology Inpatient Consult, Reason for Consult: seizure an assessment note reflected the neurologist thoughts of Resident #1's seizure activity saying it was odd that she began having seizure lately after [AGE] years without having any and said he would adjust the carbamazepine medication dosage. Record review of Resident #1's hospital admission record dated 12/06/2022 titled HMD attending attestation #AMS #Breakthrough Seizure reflected the doctor said the resident was seen by a neurologist who attested that her primary diagnosis was refractory seizure (medications are not controlling seizure activity), and AEDs were adjusted. Record review of Resident #1's hospital admission record dated 12/06/2023 titled Labs reflected a lab value reading for Phenytoin Free level (the measurement of free phenytoin level is necessary to properly evaluate the phenytoin level than that calculated from total phenytoin level) was 0.6 ug/mL (*normal reference range is 1.0 - 2.5 ug/mL). Record review of Resident #1's hospital admission record dated 12/07/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Phenytoin Level, Total - Abnormal; Notable for the following components: Phenytoin 6.0 (*normal reference range is 10.2 - 20.0 ug/mL). Record review of Resident #1's hospital admission record dated 12/08/2022 titled HMD attending attestation reflected the hospital doctor wrote the resident was stable enough for discharge and stated Resident #1's AEDs had been adjusted. Record review of Resident #1's hospital admission record dated 12/08/2022 titled HMD attending attestation, Reason for hospitalization reflected the hospital doctor wrote the resident had a seizure in route to the hospital on 12/04/2023 that lasted 1 minute and was administered 5 g of versed (relaxant). Record review of Resident #1's hospital admission record dated 12/08/2022 titled HMD attending attestation, Hospital Course / Summary reflected the hospital doctor stated neurology had adjusted the resident's carbamazepine to carbamazepine extended release and would now be taking the medication twice a day instead of three times a day and increased the dose to 400 mg BID from the previous dose which was 200 mg TID. The doctor stated Resident #1 had expressed concerns about her medical care in the NH, she wrote in part, she does not feel she is being taken care of properly there and Patient is agreeable to return to it for now and give her daughter and son time to pick out an alternative option. Record review of Resident #1's hospital admission record dated 12/08/2022 titled Discharge Medications: Medication list, STOP taking these medications, reflected Carbamazepine 200 mg tablet, commonly known as: Tegretol, Replaced by: Carbamazepine 400 mg 12 hr tablet. Record review of Resident #1's hospital admission record dated 12/08/2022 titled Patient Instructions reflected the resident had been evaluated at the hospital for breakthrough seizure activity and listed instructions noting the change in carbamazepine dosage and to take as prescribed to prevent future seizure activity. Record review of Resident #1's progress note written by ADON I on 12/12/2022 at 1:53 p.m., reflected the resident was disoriented and not responding to questions, just mumbling, the NP was notified, and Resident #1's family member was also contacted. Record review of Resident #1's progress note dated 12/12/2022 at 3:10 p.m. described Resident #1's family member's concerns and requested for Resident #1's transfer to the emergency department for further evaluation and treatment. ADON I called 911, she described Resident #1 was talking incoherently and not answering questions appropriately and noted notifying the NP and DON. Record review of Resident #1's emergency room admission record dated 12/12/2022 titled ED Provider Note, Date of Service 12/12/22, Chief Complaint reflected the patient presented with seizures. The record states the resident had a recent admission to the hospital earlier this month, no date was given, for altered mental status, she was seen by Neurology who adjusted her antiepileptic drugs. Record review of Resident #1's emergency department to hospital admission record dated 12/12/2022titled Medical Decision Making, Mon [DATE] stated, Patient here with seizure today, phenytoin level subtherapeutic. Record review of Resident #1's emergency department to hospital admission record dated 12/12/2022 titled Final Diagnoses reflected Seizure, and stated, Patient left with a disposition of Admit. Record review of Resident #1's hospital admission record dated 12/12/2022 titled Assessment & Plan, Active Problems; Seizure noted AED levels for Phenytoin(7.7), Carbamazepine(3.2), and Levetiracetam(43.4). Record review of Resident #1's hospital admission record dated 12/12/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Phenytoin Level, Total - Abnormal; Notable for the following components: Phenytoin 7.7 (*normal reference range is 10.2 - 20.0 ug/mL *). Record review of Resident #1's hospital admission record dated 12/12/2022 titled Hospital Medicine Admission History and Physical: Resident #1 reflected a chief complaint of seizure- like activity. Record review of Resident #1's hospital admission record dated 12/12/2022 titled Assessment & Plan, Active Problems; Seizure and reflected admitted here 12/04-12/08 after breakthrough seizure on 12/03 due to medication non-compliance as patient lives in a NH and reports her medications are often not given as scheduled. The record states neurology increased carbamazepine dosing from 200 mg TID to ER 400 mg BID and added, Please consult neurology in AM. Record review of Resident #1's emergency department to hospital admission record dated 12/12/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Carbamazepine blood level final result was abnormal, it was 3.2, (*normal reference range is 4.0 - 12.0 ug/mL *). Record review of Resident #1's hospital admission record dated 12/15/2022 titled Neurology Inpatient Consult, Reason for Consult: Recommendations for AED selection/dosing reflected Phenytoin level on 12/12/2022 was 7.7, Carbamazepine level on 12/12/2022 was 3.2, and Levetiracetam level on 12/12/2022 was 43.4. The document stated Resident #1's Home AEDs were Keppra 1000 mg BID, Carbamazepine XR, 400 mg BID, and Phenytoin ER 200 mg BID. Record review of Resident #1's hospital admission record dated 12/15/2022 under the Neurology Inpatient Consult titled Assessment & Plan, Impression reflected the neurologist concern for the recent presentation of Resident #1's breakthrough seizure activity, writing the likely cause for the occurrences could be due to medication non-adherence and recent check of AED levels that were low. Record review of Resident #1's emergency department to hospital admission record dated 12/12/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Phenytoin Level, Total - Abnormal; Notable for the following components: Phenytoin 7.4 (*normal reference range is 10.2 - 20.0 ug/mL). Record review of Resident #1's hospital admission record dated 12/23/2022 titled Hospital Medicine Discharge Summary reflected a discharge diagnosis of active problems were seizures. The neurologist recommended continuation of Keppra 1000 mg BID, switched Carbamazepine XR 400 mg BID back to 200 mg TID, and said to continue Phenytoin ER 200 mg BID. Record review of Resident #1's hospital admission record dated 12/23/2022 titled Discharge Medications: CHANGE how you take these medications reflected the antiseizure medication Keppra's dosage had been changed from 1000 mg BID to 1500 mg BID. During an interview on 1/19/2023 at 2:00 p.m. with the DON, stated she contacted Resident #1's NP for the change in condition instead of her PCP because at times it was hard to get a hold of the PCP. She said the documentation entered by her on 12/0 The DON she was aware of Resident #1's altered mental state and was told by ADON I, Resident #1 was transferred to the hospital. The DON said she did not speak to Resident #1's PCP because the NP was providing the care. The DON said she did not consider consulting with the Medical Director because she felt the NP was caring for Resident #1's correctly, saying the situation did not warrant a consult for additional interventions for the care of the current significant change in Resident #1's condition. The DON stated it was not normal for Resident #1 to be sent out to the hospital 3 times in December 2022, and said the resident was sent out the first time was the only time it was for seizure activity. The DON said the other 2 hospital visits were not for epileptic seizures, and that Resident #1 was sent out due to satisfy Resident #1's family wishes. The DON said she did review all 3 hospital records but did not pursue trying to get Resident #1's lab values taken during the stays. The DON said the NP reviewed the hospital discharge instructions on 1/10/22, after a visit with Resident #1, and was told by the NP that there were no new orders, and to was told by the NP to continue observe the resident for seizure activity. During an interview on 1/19/2023 at 6:22 pm with Resident #1's NP revealed she was aware of the hospitalization s that occurred during December 2022 and stated she did not inform the PCP regarding the seizures, because she was an independent practitioner and could order treatments and medications for Resident #1 medical care. The NP said she was not aware there weren't any AES labs ordered to verify antiseizure medication levels for Resident #1, saying that she had cared for the resident for many years and knew there used to be an order for the lab draws in the past and admitted not checking the orders lately. She said the orders that were once place in paper health records could have been missed, dropped off and not carried over into the new electronic system currently in use. The NP said it was a team effort by nursing staff and practitioners to catch those types of mistakes, she relied on the nursing staff to keep her informed and ask for orders. The NP said the antiseizure medication levels should be monitored for therapeutic levels in the body to rule out toxicity side effects and could say why she had not reentered lab orders. She denied being informed of any abnormal antiseizure medication levels in the past, and said she ordered some labs to be drawn on 1/08/2022, checking the results when she came into the facility on [DATE] for a visit with Resident #1, and reported the decision to nursing staff to continue with the current antiseizure medication regimen and not add any new orders. The NP stated she no longer would be in charge of Resident #1's health care and had stopped last week and could not say when the last day was before signing off as Resident #1's NP. The NP said the decision to sign off on the care was due to Resident #1's newly assigned PCP who had their own NP on board. Record review of Resident #1's clinical results electronic documentation dated from 7/11/2022 through 1/19/2023, reflected only one lab draw was ordered on 1/06/23 for therapeutic levels for Resident #1's antiseizure medications. Record review of Resident #1's laboratory results dated [DATE], reflected an abnormal level for antiseizure medication Carbamazepine, result read <2.0 L ug/mL, and a normal reference range of 4.0- 12.0. Another antiseizure medication laboratory report for Dilantin medication resulted at 4.0 ug/mL with a normal reference range of 10.0 -20.0 flagged as low. During an interview on 1/19/2022 at 6:30 p.m. with the DON, she was asked who was currently in charge of Resident #1's care, she said the NP, and was not aware the NP had discharged herself from taking care of Resident #1's health care. The DON said she was not aware of the change. She could not say who was currently overseeing Resident #1's health care. During an interview on 1/19/2022 at 7 p.m. with the Facility Medical Director, he said Resident #1's former PCP had been terminated from the care for the resident on 12/31/22, and he believed it was because the PCP was not coming to the facility to care for her patients. The Medical Director claimed he was unaware of Resident #1's December 2022 hospitalization s, and stated he was not familiar with the resident at all, saying that she was not his patient and therefore would not know of her or her recent seizure activity. He was asked what the protocol was for the care of residents who had a diagnosis of epilepsy that were admitted to the facility, and he said, initial labs need to be ordered to assess whether the residents are experiencing therapeutic levels of ordered antiseizure medications. Then he said, for normal levels, he stated ordering labs should be paced and drawn every 3 months. The Medical Director explained if the antiseizure medication level are abnormal, the practice is to order the labs to be drawn every week until the levels are therapeutic and then they are ordered once a month for 6 months, with instructions for close monitoring of seizure activity symptoms. The Medical Director stated he expects the nursing staff to observe for toxicity signs and symptoms, confusion, body jerking movements, and fainting, the nursing staff should alert the MD immediately for intervention orders. He said if a resident goes on having seizures and there are no interventions ordered, the residents could be affected with status epilepticus which is a common form of emergency situation that can occur with prolonged or repeated seizure activity, causing convulsions and possibly death. During an interview on 1/19/2022 at 7:15 p.m. with Resident #1's new PCP, she denied knowing Resident #1'shad been recently hospitalized three different times in December 2022 for new onset seizure activity. The new PCP mentioned t she had just been given the assignment to take over Resident #1 's care the week of 1/09/22and had not been to the facility to assess Resident #1 , adding she would be coming next week to perform a thorough history and physical. The new PCP said her process for care of an admitted epileptic resident taking antiseizure medications was to order the nursing staff to monitor for symptoms of seizures including toxicity, and notifying the MD with concerns, and abnormal lab values. She stated when she takes over the care of a new resident, she will order labs to find out the current base line of the medication levels. She stated if they are abnormal, she will change dosages to antiseizure medications and check blood levels in one week until the drugs reached the proper therapeutic level in a person. She stated after reaching the normal level she will order antiseizure medication levels once a month until she was assured the person medication blood levers were safe. The new PCP stated after that she orders the labs to be drawn every 6 months. The newly assigned PCP said she checks the labs each time she comes to visit the resident, once a week, and expects the nurses to call her any time with any changes. The new PCP said the outcome for residents not being properly monitored after having a new onset of seizures is that they can end up in unnecessarily the hospital with longer and stronger seizure activity. During an interview on 1/20/2022 at 1:20 p.m. with the Administrator revealed Resident #1's PCP had been, pulling away from the facility, and he was asked to clarify pulling away. He stated the PCP was not rounding with her residents as much as needed. The Administrator was asked if the PCP had been fired from caring for Resident #1, and he stated that was not true, and that he had not fired her. The Administrator was told the Medical Director had mentioned the facility had fired the PCP, and he said he did not know Resident #1, her situation of rehospitalization s because he said, she is not my patient. The Administrator stated that indeed the Medical Director knew Resident #1, and that he would advise the Medical Director the PCP had not been fired from Resident #1's care, he added that the reason the Medical Director had said he did not know the resident may have happened because The Medical Director did not directly provide care for Resident #1. The Administrator said, due to the prior PCP, pulling away from her residents, he decided to approach the PCP in November 2022 to ask her if she accepted help to lessen her resident load, by asking some of her current residents if they wanted a new MD, and said she agreed to release whoever requested another practitioner. The Administrator said a total of 5 residents agreed with the suggestion to receive care from a new MD. He said the last time the PCP saw Resident #1 was on 1/06/2023. The Administrator was asked if he was aware of the NP's allegation that she was no longer caring for Resident #1, stating she had resigned from Resident #1's care earlier that week, and denied knowing the NP had stopped care. He was asked who was currently in charge of Resident #1's care and he said, That is a good question and added, I will need to find out. The Administrator was asked whether nursing had notified him of a change of condition for Resident #1's health status and he said the DON did the first time the resident went out the hospital in December 2022. He stated that Resident #1's change in condition was brought up several times in December 2022, discussed by an interdisciplinary weekly resident meeting, and during the meeting it was deemed she had a significant change in condition from her normal state, stating he was informed the resident became confused, and had a seizure on 12/03/22. The Administrator said he leads the meetings, and he expects nursing staff to follow up with physicians to discuss health interventions, such as new orders, treatments, or labs to determine the cause for the change in health status. The Administrator was asked if there are other times beside the weekly meetings a resident's change in condition is discussed and he mentioned during QAPI meetings, changes in conditions are examined, as well as new or worsened wounds, and falls. He said during those meetings, care plans are reviewed, updated, or completed, and new action plans are added to a revised plan of care. He said the last QAPI was on 1/06/2023, and acknowledged Resident #1 was not specifically dis [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs and included adequate monitoring for high-risk medications for 1 (Resident #1) of 5 residents reviewed for antiseizure medications. The facility failed to Monitor Resident #1 antiseizure medications therapeutic blood levels. -Resident #1 was transferred to the hospital three different times in the month of December 2022 because the DON deemed the transfer to the emergency room was necessary due to unstable symptoms of altered mental status. The facility failed to follow up on the pharmacist consult recommended antiseizure medication interaction to ensure therapeutic medication labs were ordered and uploaded to Resident #1's medical record. The facility failed to inform the attending physician of antiseizure medication interventions recommended by the pharmacist to safely manage Resident #1's epileptic diagnosis. This failure resulted in identification of Immediate Jeopardy (IJ) on 1/20/2023 at 4:40 p.m. The IJ was removed on 1/21/2023 at 3:50 P.M. The facility remained out of compliance at a scope of a pattern and actual harm with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents receiving psychotropic medications at risk for adverse side effects and consequences, including altered mental status, a decreased quality of life, a change in condition, and death. Findings included: Record review of Resident #1's Face Sheet dated 1/19/2023 indicated she was a [AGE] year-old female admitted to the facility on [DATE], with a recent readmitted [DATE]. Resident #1's diagnoses included, unspecified convulsions, status epilepticus (seizure that lasts too long or when seizures occur close together and the person doesn't recover between seizures), diabetes, muscle weakness, reduced mobility, high blood pressure, heart disease, arthritis, and anemia (lack of enough healthy red blood cells to carry adequate oxygen to body's tissues). Record review of Resident #1's MDS dated [DATE] reflected a reentry date of 12/23/2022 from an acute (sudden) hospital stay. The MDS noted the date the episode for transfer to hospital began was on 12/08/2022. Resident #1's BIMS score was an 11 , which indicated moderate cognitive impairment per brief interview for mental status. Resident #1 required extensive physical assist with bed mobility, transfer between surfaces, dressing, toilet use, personal hygiene, locomotion on and off the unit using a wheelchair as a mobility device and only able to stabilize with staff assistance. Resident #1 had no behavioral symptoms during the MDS review period. Record review of Resident #1's Care Plan dated 12/28/2022 indicated she had a seizure disorder, and the goal was to help her remain free from injury related to seizure activity and reflected an additional goal to maintain lab values within a therapeutic range. Resident #1's care planned interventions indicated the following: -give the medications as ordered. Monitor and document for effectiveness and side effects. -monitor labs and report any sub therapeutic or toxic results to the MD. -obtain and monitor lab/diagnostic work as ordered. Report results to the MD as follow up as indicated. Interview on 1/19/23 at 10:00 am with Resident #1's family member, she said Resident #1 had not had any seizures for many years, and said she recently had three visits to the hospital in December 2022 after having seizures. She thinks the cause for the re occurrences of the seizures is due to facility nurses not giving Resident #1's antiseizure medications correctly and the resident told her the nurses were not giving her the medications as prescribed and skipping giving her doses. Resident #1's family member said that she was told by MDs at the hospital that the cause for the new onset seizure activity may have been due to labs not being drawn in a constant manner, and the medication not being provided as prescribed. Resident #1's family member said she was also told by the hospital MD's Resident #1's antiseizure medication levels were low and that is why she was having seizure, and that is the reason Resident #1's family member called the State Health and Human services to complain about the resident's care, and to have someone come out and investigate the facility. Interview on 1/19/23 at 10:15 am with Resident #1, the resident was in bed and revealed she was upset for the last three visits to the hospital emergency room because she started having seizure again. Resident #1 was teary and gloomy, saying she had lived in the facility for about [AGE] years and for many of those years she had not experienced seizures. Resident #1 said that maybe the seizures began because the nursing staff would take long bringing her morning and evening medications, and said she thought they did not give her some of the doses. Review of Resident #1's Clinical Physician's Orders, dated 12/01/2022 reflected the resident had orders for antiseizure medications as follows: -Carbamazepine tablet 200 mg, give 1 tablet by mouth before meals for seizures, order date was 6/29/2022 -Dilantin capsule, five 200 mg, give by mouth two times as day related to epilepsy, order date was 6/29/2022 -Levetiracetam tablet 1000 mg, give 1 tablet by mouth two times a day for seizures related to epilepsy, order date was 7/06/2022. -Resident #1's Clinical Physician Orders did not include instructions for antiseizure medication lab draws. Record review of Resident #1's Consultant Pharmacist's Medication Regimen Review document dated 7/01/2022 through 7/18/2022 reflected a pharmacist's recommendation to check Dilantin and Carbamazepine blood levels, suggested to ensure lab result levels were current in Resident #1's electronic medical record for review for AED medications Dilantin and Carbamazepine, the suggestion was signed off by the DON, she signed off by adding a notation completed. Record review of Resident #1's Consultant Pharmacist's Medication Regimen Review document dated 10/01/2022 through 10/17/2022 reflected a pharmacist's recommendation to check Dilantin and Carbamazepine blood levels, suggested to ensure lab result levels were current in Resident #1's electronic medical record for review for AED medications Dilantin and Carbamazepine, the suggestion was signed off by the DON. Record review of Resident #1's Consultant Pharmacist's Medication Regimen Review document dated 12/01/2022 through 12/12/2022 reflected a pharmacist's recommendation to check Dilantin and Carbamazepine blood levels, suggested to ensure lab result levels were current in Resident #1's electronic medical record for review for AED medications Dilantin and Carbamazepine, the suggestion was signed off by the DON and she added the labs were ordered but Resident #1 had been sent to the hospital. Record review of Resident #1s Progress Note written by ADON I dated 12/03/2022 at reflected Resident #1 was in bed and ADON I documented an observation of the resident having some confusion, complaining of headache, and did not note the resident having a seizure. ADON I documented Resident #1 stated she felt like she was going to have a seizure and called 911 per Resident #1's request. The note reflected the resident was transferred to the emergency room , and ADON I called and notified the NP. Record review of Resident #1's emergency room stay on 12/03/2022 reflected she was discharged back to the nursing facility on 12/03/22with seizure discharge instructions and to follow up with the hospital in 3 days if symptoms worsened. The record reflected for Resident #1 to follow up with a neurologist in 1 week, the name, phone number and address were provided on the discharge paperwork, and according to DON the neurologist appointment was not made because of Resident #1 until 12/27/22 due to Resident #1's numerous hospitalization s. The record reflected the reason for the emergency department visit was due to seizures. Record review of Resident #1's emergency room admission record dated 12/03/2022 titled Lab Tests Completed reflected in part some of the lab's levels that were during the visit included, Carbamazepine and Phenytoin. Record review of Resident #1's emergency room admission record dated 12/03/2022 titled Lab Results reflected Carbamazepine blood level final result was abnormal, it was 3.2, (*normal reference range is 4.0 - 12.0 ug/mL *) and Phenytoin level at 6.0 (*normal reference range is 10.2 - 20.0 ug/mL). Record review of Resident #1's emergency room admission record dated 12/03/2022 titled Medications given reflected the resident received AED medications and none of the doses had been changed. Record review of Resident #1's emergency room discharge instructions dated 12/03/2022 reflected there were no upcoming doctor appointments scheduled, and to continue with the same medication regimen she was currently taking at the NH. During an interview on 1/19/2023 at 12:48 p.m. with ADON I, she said Resident #1 came back after midnight on 12/4/2022. ADON I stated the NP had ordered AED labs to be drawn on 12/04/22 but had not been drawn due to Resident #1's request to be sent back to the emergency department on 12/04/22. ADON I denied knowing the recommendations by the pharmacy consultant for therapeutic lab values were drawn prior to the emergency room visit and said and said she had not reviewed the hospital discharge instructions and when a resident was readmitted to the facility after a hospital stay it was the nursing administration teams responsibility to go over the records and implement any appointments or new orders. Record review of Resident #1s Progress Note written by ADON I and dated 12/04/2022 reflected Resident #1's family member told her she wanted Resident #1 to be sent out to the hospital be reassessed for seizures. ADON I wrote she observed Resident #1 in her room having a seizure lasting about 60 seconds, and when the seizure became less intense and ended, the patient returned to normal. ADON I called EMS who came to transfer Resident #1 to the hospital, and ADON I documented that the resident was observed to continue being disoriented on exit. During an interview on 1/19/2023 at 1:35 p.m. with ADON I, she said Resident #1's family member was in the room dressing her on 12/03/22 when the family member called out to say Resident #1 got hot and began perspiring,, the ADON I came into the room, and Resident #1 had calmed down, but the resident was looking at the ADON with a blank stare and not moving. ADON I said she thought Resident #1 was having a seizure, and she said, Once she came out of it, she was confused and called 911 for transport to the hospital. ADON I said Resident #1's family member told her Resident #1 had not had a seizure for [AGE] years. The ADON stated the recent seizure activity was out of the norm for Resident #1. ADON I said she notified the resident's NP regarding the hospital transfer. Record review of Resident #1's emergency room admission record dated 12/04/2022 titled ED Provider Note, Date of Service 12/04/2022, Chief Complaint reflected the patient presented to the emergency room with altered mental status problems and weakness. The physician stated Resident #1 had symptoms of altered mental status and questioned whether it was related to a seizure, noted the resident was taking Keppra, Dilantin, Tegretol, and stated an emergency medical clinician had witnessed the resident had a seizure while in route to the hospital from the nursing home and had been given versed (an anticonvulsant medication) which helped to stop the seizures. The ED physician also noted Resident #1 had been seen at another hospital on 12/03/2022 for a seizure. Record review of Resident #1's emergency room admission record dated 12/04/2022 titled ED Provider Note, Date of Service 12/04/2022, Chief Complaint reflected the patient presented to the emergency room with altered mental status problems and weakness. The physician stated Resident #1 had symptoms of altered mental status and questioned whether it was related to a seizure, noted the resident was taking Keppra, Dilantin, Tegretol, and stated an emergency medical clinician had witnessed the resident had a seizure while in route to the hospital from the nursing home and had been given versed (an anticonvulsant medication) which helped to stop the seizures. The ED physician also noted Resident #1 had been seen at another hospital on 12/03/2022 for a seizure. Record review of Resident #1's emergency room admission record dated 12/04/2022 titled Physical Exam Review of Systems (review of systems is an inventory of the body systems that is obtained through a series of questions in order to identify signs and/or symptoms which the patient may be experiencing) referenced Resident #1 was unable to be reviewed because she had a mental status change that prevented her from answering medical questions. Record review of Resident #1's emergency department to hospital admission record dated 12/04/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Phenytoin Level, Total - Abnormal; Notable for the following components: Phenytoin 6.7 (*normal reference range is 10.2 - 20.0 ug/mL). Record review of Resident #1's emergency department to hospital admission record dated 12/04/2022 titled Final Diagnoses reflected an admission diagnose of altered mental status, and stated, Patient left with a disposition of Admit. Record review of Resident #1's hospital admission record dated 12/05/2022 titled Hospital Medicine Admission History and Physical: Resident #1 reflected a chief complaint of altered mental status and weakness symptoms, and review of systems were noted to have lack of energy, headache, and confusion. Record review of Resident #1's hospital admission record dated 12/05/2022 titled Assessment & Plan Active Problems: # Seizure disorder, Continue Keppra 1000 mg BID, Phenytoin 200 mg BID, Carbamazepine 200 mg TID, Neurology referral on discharge. Record review of Resident #1's hospital admission record dated 12/05/2022 titled Neurology Inpatient Consult, Reason for Consult: seizure an assessment note reflected the neurologist thoughts of Resident #1's seizure activity saying it was odd that she began having seizure lately after [AGE] years without having any and said he would adjust the carbamazepine medication dosage. Record review of Resident #1's hospital admission record dated 12/06/2022 titled HMD attending attestation #AMS #Breakthrough Seizure reflected the doctor said the resident was seen by a neurologist who attested that her primary diagnosis was refractory seizure (medications are not controlling seizure activity), and AEDs were adjusted. Record review of Resident #1's hospital admission record dated 12/06/2023 titled Labs reflected a lab value reading for Phenytoin Free level (the measurement of free phenytoin level is necessary to properly evaluate the phenytoin level than that calculated from total phenytoin level) was 0.6 ug/mL (*normal reference range is 1.0 - 2.5 ug/mL). Record review of Resident #1's hospital admission record dated 12/07/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Phenytoin Level, Total - Abnormal; Notable for the following components: Phenytoin 6.0 (*normal reference range is 10.2 - 20.0 ug/mL). Record review of Resident #1's hospital admission record dated 12/08/2022 titled HMD attending attestation reflected the hospital doctor wrote the resident was stable enough for discharge and stated Resident #1's AEDs had been adjusted. Record review of Resident #1's hospital admission record dated 12/08/2022 titled HMD attending attestation, Reason for hospitalization reflected the hospital doctor wrote the resident had a seizure in route to the hospital on 12/04/2023 that lasted 1 minute and was administered 5 g of versed (relaxant). Record review of Resident #1's hospital admission record dated 12/08/2022 titled HMD attending attestation, Hospital Course / Summary reflected the hospital doctor stated neurology had adjusted the resident's carbamazepine to carbamazepine extended release and would now be taking the medication twice a day instead of three times a day and increased the dose to 400 mg BID from the previous dose which was 200 mg TID. The doctor stated Resident #1 had expressed concerns about her medical care in the NH, she wrote in part, she does not feel she is being taken care of properly there and Patient is agreeable to return to it for now and give her daughter and son time to pick out an alternative option. Record review of Resident #1's hospital admission record dated 12/08/2022 titled Discharge Medications: Medication list, STOP taking these medications, reflected Carbamazepine 200 mg tablet, commonly known as: Tegretol, Replaced by: Carbamazepine 400 mg 12 hr tablet. Record review of Resident #1's hospital admission record dated 12/08/2022 titled Patient Instructions reflected the resident had been evaluated at the hospital for breakthrough seizure activity and listed instructions noting the change in carbamazepine dosage and to take as prescribed to prevent future seizure activity. Record review of Resident #1's progress note written by ADON I on 12/12/2022 at 1:53 p.m., reflected the resident was disoriented and not responding to questions, just mumbling, the NP was notified, and Resident #1's family member was also contacted. Record review of Resident #1's progress note dated 12/12/2022 at 3:10 p.m. described Resident #1's family member's concerns and requested for Resident #1's transfer to the emergency department for further evaluation and treatment. ADON I called 911, she described Resident #1 was talking incoherently and not answering questions appropriately and noted notifying the NP and DON. Record review of Resident #1's emergency room admission record dated 12/12/2022 titled ED Provider Note, Date of Service 12/12/22, Chief Complaint reflected the patient presented with seizures. The record states the resident had a recent admission to the hospital earlier this month, no date was given, for altered mental status, she was seen by Neurology who adjusted her antiepileptic drugs. Record review of Resident #1's emergency department to hospital admission record dated 12/12/2022titled Medical Decision Making, Mon [DATE] stated, Patient here with seizure today, phenytoin level subtherapeutic. Record review of Resident #1's emergency department to hospital admission record dated 12/12/2022 titled Final Diagnoses reflected Seizure, and stated, Patient left with a disposition of Admit. Record review of Resident #1's hospital admission record dated 12/12/2022 titled Assessment & Plan, Active Problems; Seizure noted AED levels for Phenytoin(7.7), Carbamazepine(3.2), and Levetiracetam(43.4). Record review of Resident #1's hospital admission record dated 12/12/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Phenytoin Level, Total - Abnormal; Notable for the following components: Phenytoin 7.7 (*normal reference range is 10.2 - 20.0 ug/mL *). Record review of Resident #1's hospital admission record dated 12/12/2022 titled Hospital Medicine Admission History and Physical: Resident #1 reflected a chief complaint of seizure- like activity. Record review of Resident #1's hospital admission record dated 12/12/2022 titled Assessment & Plan, Active Problems; Seizure and reflected admitted here 12/04-12/08 after breakthrough seizure on 12/03 due to medication non-compliance as patient lives in a NH and reports her medications are often not given as scheduled. The record states neurology increased carbamazepine dosing from 200 mg TID to ER 400 mg BID and added, Please consult neurology in AM. Record review of Resident #1's emergency department to hospital admission record dated 12/12/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Carbamazepine blood level final result was abnormal, it was 3.2, (*normal reference range is 4.0 - 12.0 ug/mL *). Record review of Resident #1's hospital admission record dated 12/15/2022 titled Neurology Inpatient Consult, Reason for Consult: Recommendations for AED selection/dosing reflected Phenytoin level on 12/12/2022 was 7.7, Carbamazepine level on 12/12/2022 was 3.2, and Levetiracetam level on 12/12/2022 was 43.4. The document stated Resident #1's Home AEDs were Keppra 1000 mg BID, Carbamazepine XR, 400 mg BID, and Phenytoin ER 200 mg BID. Record review of Resident #1's hospital admission record dated 12/15/2022 under the Neurology Inpatient Consult titled Assessment & Plan, Impression reflected the neurologist concern for the recent presentation of Resident #1's breakthrough seizure activity, writing the likely cause for the occurrences could be due to medication non-adherence and recent check of AED levels that were low. Record review of Resident #1's emergency department to hospital admission record dated 12/12/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Phenytoin Level, Total - Abnormal; Notable for the following components: Phenytoin 7.4 (*normal reference range is 10.2 - 20.0 ug/mL). Record review of Resident #1's hospital admission record dated 12/23/2022 titled Hospital Medicine Discharge Summary reflected a discharge diagnosis of active problems were seizures. The neurologist recommended continuation of Keppra 1000 mg BID, switched Carbamazepine XR 400 mg BID back to 200 mg TID, and said to continue Phenytoin ER 200 mg BID. Record review of Resident #1's hospital admission record dated 12/23/2022 titled Discharge Medications: CHANGE how you take these medications reflected the antiseizure medication Keppra's dosage had been changed from 1000 mg BID to 1500 mg BID. During an interview on 1/19/2023 at 2:00 p.m. with the DON, stated she contacted Resident #1's NP for the change in condition instead of her PCP because at times it was hard to get a hold of the PCP. She said the documentation entered by her on 12/0 The DON she was aware of Resident #1's altered mental state and was told by ADON I, Resident #1 was transferred to the hospital. The DON said she did not speak to Resident #1's PCP because the NP was providing the care. The DON said she did not consider consulting with the Medical Director because she felt the NP was caring for Resident #1's correctly, saying the situation did not warrant a consult for additional interventions for the care of the current significant change in Resident #1's condition. The DON stated it was not normal for Resident #1 to be sent out to the hospital 3 times in December 2022, and said the resident was sent out the first time was the only time it was for seizure activity. The DON said the other 2 hospital visits were not for epileptic seizures, and that Resident #1 was sent out due to satisfy Resident #1's family wishes. The DON said she did review all 3 hospital records but did not pursue trying to get Resident #1's lab values taken during the stays. The DON said the NP reviewed the hospital discharge instructions on 1/10/22, after a visit with Resident #1, and was told by the NP that there were no new orders, and to was told by the NP to continue observe the resident for seizure activity. During an interview on 1/19/2023 at 6:22 pm with Resident #1's NP revealed she was aware of the hospitalization s that occurred during December 2022 and stated she did not inform the PCP regarding the seizures, because she was an independent practitioner and could order treatments and medications for Resident #1 medical care. The NP said she was not aware there weren't any AES labs ordered to verify antiseizure medication levels for Resident #1, saying that she had cared for the resident for many years and knew there used to be an order for the lab draws in the past and admitted not checking the orders lately. She said the orders that were once place in paper health records could have been missed, dropped off and not carried over into the new electronic system currently in use. The NP said it was a team effort by nursing staff and practitioners to catch those types of mistakes, she relied on the nursing staff to keep her informed and ask for orders. The NP said the antiseizure medication levels should be monitored for therapeutic levels in the body to rule out toxicity side effects and could say why she had not reentered lab orders. She denied being informed of any abnormal antiseizure medication levels in the past, and said she ordered some labs to be drawn on 1/08/2022, checking the results when she came into the facility on [DATE] for a visit with Resident #1, and reported the decision to nursing staff to continue with the current antiseizure medication regimen and not add any new orders. The NP stated she no longer would be in charge of Resident #1's health care and had stopped last week and could not say when the last day was before signing off as Resident #1's NP. The NP said the decision to sign off on the care was due to Resident #1's newly assigned PCP who had their own NP on board. Record review of Resident #1's clinical results electronic documentation dated from 7/11/2022 through 1/19/2023, reflected only one lab draw was ordered on 1/06/23 for therapeutic levels for Resident #1's antiseizure medications. Record review of Resident #1's laboratory results dated [DATE], reflected an abnormal level for antiseizure medication Carbamazepine, result read <2.0 L ug/mL, and a normal reference range of 4.0- 12.0. Another antiseizure medication laboratory report for Dilantin medication resulted at 4.0 ug/mL with a normal reference range of 10.0 -20.0 flagged as low. During an interview on 1/19/2022 at 6:30 p.m. with the DON, she was asked who was currently in charge of Resident #1's care, she said the NP, and was not aware the NP had discharged herself from taking care of Resident #1's health care. The DON said she was not aware of the change. She could not say who was currently overseeing Resident #1's health care. During an interview on 1/19/2022 at 7 p.m. with the Facility Medical Director, he said Resident #1's former PCP had been terminated from the care for the resident on 12/31/22, and he believed it was because the PCP was not coming to the facility to care for her patients. The Medical Director claimed he was unaware of Resident #1's December 2022 hospitalization s, and stated he was not familiar with the resident at all, saying that she was not his patient and therefore would not know of her or her recent seizure activity. He was asked what the protocol was for the care of residents who had a diagnosis of epilepsy that were admitted to the facility, and he said, initial labs need to be ordered to assess whether the residents are experiencing therapeutic levels of ordered antiseizure medications. Then he said, for normal levels, he stated ordering labs should be paced and drawn every 3 months. The Medical Director explained if the antiseizure medication level are abnormal, the practice is to order the labs to be drawn every week until the levels are therapeutic and then they are ordered once a month for 6 months, with instructions for close monitoring of seizure activity symptoms. The Medical Director stated he expects the nursing staff to observe for toxicity signs and symptoms, confusion, body jerking movements, and fainting, the nursing staff should alert the MD immediately for intervention orders. He said if a resident goes on having seizures and there are no interventions ordered, the residents could be affected with status epilepticus which is a common form of emergency situation that can occur with prolonged or repeated seizure activity, causing convulsions and possibly death. During an interview on 1/19/2022 at 7:15 p.m. with Resident #1's new PCP, she denied knowing Resident #1'shad been recently hospitalized three different times in December 2022 for new onset seizure activity. The new PCP mentioned t she had just been given the assignment to take over Resident #1 's care the week of 1/09/22and had not been to the facility to assess Resident #1 , adding she would be coming next week to perform a thorough history and physical. The new PCP said her process for care of an admitted epileptic resident taking antiseizure medications was to order the nursing staff to monitor for symptoms of seizures including toxicity, and notifying the MD with concerns, and abnormal lab values. She stated when she takes over the care of a new resident, she will order labs to find out the current base line of the medication levels. She stated if they are abnormal, she will change dosages to antiseizure medications and check blood levels in one week until the drugs reached the proper therapeutic level in a person. She stated after reaching the normal level she will order antiseizure medication levels once a month until she was assured the person medication blood levers were safe. The new PCP stated after that she orders the labs to be drawn every 6 months. The newly assigned PCP said she checks the labs each time she comes to visit the resident, once a week, and expects the nurses to call her any time with any changes. The new PCP said the outcome for residents not being properly monitored after having a new onset of seizures is that they can end up in unnecessarily the hospital with longer and stronger seizure activity. During an interview on 1/20/2022 at 1:20 p.m. with the Administrator revealed Resident #1's PCP had been, pulling away from the facility, and he was asked to clarify pulling away. He stated the PCP was not rounding with her residents as much as needed. The Administrator was asked if the PCP had been fired from caring for Resident #1, and he stated that was not true, and that he had not fired her. The Administrator was told the Medical Director had mentioned the facility had fired the PCP, and he said he did not know Resident #1, her situation of rehospitalization s because he said, she is not my patient. The Administrator stated that indeed the Medical Director knew Resident #1, and that he would advise the Medical Director the PCP had not been fired from Resident #1's care, he added that the reason the Medical Director had said he did not know the resident may have happened because The Medical Director did not directly provide care for Resident #1. The Administrator said, due to the prior PCP, pulling away from her residents, he decided to approach the PCP in November 2022 to ask her if she accepted help to lessen her resident load, by asking some of her current residents if they wanted a new MD, and said she agreed to release whoever requested another practitioner. The Administrator said a total of 5 residents agreed with the suggestion to receive care from a new MD. He said the last time the PCP saw Resident #1 was on 1/06/2023. The Administrator was asked if he was aware of the NP's allegation that she was no longer caring for Resident #1, stating she had resigned from Resident #1's care earlier that week, and denied knowing the NP had stopped care. He was asked who was currently in charge of Resident #1's care and he said, That is a good question and added, I will need to find out. The Administrator was asked whether nursing had notified him of a change of condition for Resident #1's health status and he said the DON did the first time the resident went out the hospital in December 2022. He stated that Resident #1's change in condition was brought up several times in December 2022, discussed by an interdisciplinary weekly resident meeting, and during the meeting it was deemed she had a significant change in condition from her normal state, stating he was informed the resident became confused, and had a seizure on 12/03/22. The Administrator said he leads the meetings, and he expects nursing staff to follow up with physicians to discuss health interventions, such as new orders, treatments, or labs to determine the cause for the change in health status. The Administrator was asked if there are other times [TRUNCATED]

Based on interviews, observations, and record review, the facility failed to ensure a resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of six residents reviewed for safety, accident/hazards and supervision, in that: On 04/15/2022 CNA A failed to use a two-person transfer, based on the resident's level of assistance, during a transfer from the resident's wheelchair to the shower chair. The Resident was later diagnosed with a [CONDITION(S)]. sustaining an injury of an unknown origin. This was determined to be past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. This failure placed residents at risk for pain, significant injury, and decreased level of functioning and quality of life. Findings included: Review of Resident #1's clinical records indicated the resident was a [AGE] year-old female admitted to the facility on [DATE]. She had a history of medically complex conditions and diagnoses including [CONDITION(S)] - right side weakness (paralysis of right side of the body); Seizures; Muscle wasting & atrophy (gradual decline in effectiveness); and Other specified disorder of bone density and structure. Record review of the most recent annual MDS assessment dated [DATE] indicated the resident had a BIMS score of 2 which showed the resident's cognition was severely impaired per staff assessment. Resident #1 is always incontinent of bowel and bladder. The MDS indicated the Resident #1's Activities of Daily Living (ADL) Assistance required Two+ persons physical assist for transfer (that excluded to/from bath/toilet). The resident was Total Dependent in bathing and required Two+ persons physical assist. Review of Resident #1's care plan created on 11/11/2021 indicated Resident #1 is able to transfer with two persons assist. Revised on 04/19/2022, the resident is able to transfer with 2-person assist using a mechanical lift. Interventions included wheelchair and assistive devices for transfer was changed from gait belt to Mechanical lift on 04/15/2022 as needed for a safe transfer. Review of the Kardex (plan of care for CNA's to review resident care needs and level of assistance) indicated Two+ persons physical assist to transfer. A review of an incident report entered on 04/15/2022 at 8:58 AM by LVN C revealed the nursing incident description staff member assisting resident transfer . resident began to slip to floor, staff assisted elder down to floor using gait belt. Resident is aphasic (unable to communicate effectively with others). The incident report description of immediate action taken by LVN C, rom (range of motion) to limbs on both sides. No complaint of pain. Skin checked for bruising or tears. Level of pain was rated at a 4, no injuries observed post incident. Predisposing environmental factors identified was a wet floor. Gait imbalance was listed as a predisposing physiological factor. And Predisposing situation factor was during transfer. There were no written statements from the CNA. Review of nursing notes dated 4/15/2022 at 11:54 AM, LVN C wrote that the diagnostic company arrived to conduct an x-ray of both hips. A result of a right hip fracture in x-ray findings and resident was transferred to hospital for evaluation. Nursing notes indicated the resident returned to the facility 04/15/2022 at 6:30 PM. Review of the discharge paperwork dated 4/15/2022 indicated Resident #1 was treated for pain related to closed intertrochanteric fracture (break of the femur [thigh bone] between the greater and the lesser trochanter [joint with the thigh bone] of right hip. Review of nursing notes dated 4/16/2022 at 3:38 AM indicated the resident remained in pain, difficult to provide care, and pain meds (Tylenol 325 mg, 2 tabs) were ineffective. Resident #1 was transferred to the hospital after 911 was called. Nursing notes dated 4/16/2022 at 12:09 PM indicated Resident #1 returned to facility at 7:30 AM that morning. There were new orders for Resident #1 to follow up with an orthopedic doctor, [MEDICATION(S)]-Acetaminophen 5-325 mg, 1 tablet by mouth every 8 hours as needed for pain and Tylenol #3, 1 tablet by mouth every 6 hours as needed for severe pain (7 - 10/10). Review of progress notes by the NP on 04/18/2022 revealed Resident #1 complained of pain to right hip; positive [CONDITION(S)] (loss of ability to understand or express speech, caused by brain damage); positive decreased range of motion; positive muscle atrophy (loss of muscle tissue) and muscle weakness. Documentation further indicate Resident #1 is non ambulatory, require follow up with an Ortho MD as soon as possible, physical therapy for therapeutic exercises, balance, and wheelchair mobility training. Occupational therapy for functional mobility, equipment evaluation, ADL training, and safety. Treatment goals to return to previous level of functioning. Review of notes entered by MSW on 4/19/2022 at 2:19 PM to set an appointment with Ortho MD. Documentation further revealed the DON also attempted to schedule follow up ortho appt per MD related to pathological fx/severe osteopenia [a condition when bones get weaker but not so far gone that bones break easily] of bilateral extremities (right and left legs) several referrals sent but unable to schedule due to insurance; charge nurse will f/u with MD for further recommendation. Review of nurse progress notes entered on 4/29/2022 at 6:49 PM that Resident #1 was transferred by the facility to ER for unrelieved pain and discharged from the facility to the hospital. During a phone interview on 05/11/2022 at 5:28 PM, CNA A recalled an incident on 04/15/2022 when the resident foot must have slipped or something. CNA A said she assisted Resident #1 to the shower stall floor using the gait belt after noticing Resident #1 was losing her balance when being transferred from wheelchair to shower chair. CNA A said she called out for help for the nurse. LVN C arrived to assess the resident. CNA A left to get a mechanical lift to assist Resident #1 from the floor and transported the resident to her room and lowered her into the bed with LVN C's assistance. A follow up phone interview on 05/12/2022 at 11:56 AM with CNA A revealed Resident #1 required a two-person assist with all transfers per the plan of care and CNA B was present in the shower room retrieving the shower chair when the incident occurred. CNA A said she received training during new hire orientation and an in-service after the incident. During an interview on 05/12/2022 at 8:00 AM, LVN C stated that CNA A approached her at the nursing station to inform that Resident #1 was on the floor and needed to be assessed. LVN C said that she entered the shower room, observed Resident #1 sitting upright on the floor in the shower stall with legs straight out in front of her and appeared wet like she had just been rinsed off. When asked, LVN C did not recall if another CNA was present; she said she wasn't paying attention being focused on Resident #1. LVN C stated she performed a head-to-toe assessment. No injuries, bruising, or signs of trauma were found. Resident #1 denied pain. LVN C said Resident #1 was assisted on to a sling and raised by the mechanical lift and transported via mechanical lift to her room and bed. LVN C said the doctor was called and received an order for an x-ray of Resident #1 right and left hips. Resident #1 did not have pain concerns before the incident. On 05/12/2022 at 9:00 AM, CNA D and CNA F were observed transferring a resident from a mechanical lift sling to a shower gurney using a gait belt. During the transfer one team member using light hands-on pressure to guide patient while the other team member controlled the mechanical lift. Verbal communication between staff members and with resident to ensure comfort was noted. Proper transfer techniques were followed as directed in mechanical lift policy and the residents plan of care. Individual interviews with observed staff members indicated knowledge of proper transfer techniques, safety measures, and where to locate information about a resident transfer need. On 05/12/2022 at 11:30 AM, CNA D and CNA B were observed transferring a resident with [CONDITION(S)], left side weakness, from a wheelchair to a shower chair using a gait belt for bathing. The team demonstrated appropriate safe transfer techniques according to the resident's plan of care. Each team member had two hands on the gait belt when assisting resident to a raised position from wheelchair (ensured brakes were locked first) as the resident held on to a grab bar. One CNA maintained two hands on the gait belt and the other CNA continued to grasp the gait belt with one hand while pulling back the wheelchair and positioning the shower chair behind the resident; the CNA placed other hand on the gait belt and both CNAs assisted the resident down into the shower chair. Interview on 05/12/2022 at 12:51 PM with MSW and review of MSW's progress notes dated 04/19/2022 indicated MSW was informed Resident #1's insurance was not accepted by the referred Orthopedic MD. The MSW said she attempted to activate the referral with the county hospital district on 04/22/2022 and was told to try calling back Wednesday or Thursday. A progress note entered by the MSW dated 04/25/2022 indicated the county health & hospital system informed Resident #1's insurance could not be accepted and should go to the ER where the insurance will be verified again. The resident was sent out to the ER where she was admitted . During an interview on 05/12/2022 at 1:18 PM, CNA B stated that on the day of the incident, she was asked by CNA A to assist with showering Resident #1 and agreed to help. CNA B went on to state that the two assisted Resident #1 to a standing position using a gait belt and Resident #1 held on to the grab bar in the shower stall. CNA B stated that the resident must have become weak while holding on to the rail and started to go down while CNA B was reaching for the shower chair, and that's when CNA A assisted (Resident #1) to the floor. CNA B demonstrated partially turning away from (the right side) of the resident, taking a step (approximately 12 inches), and (leaning slightly forward) reaching out to grab the shower chair with her left arm. CNA B maintained her right arm by her side during this demonstration. When asked, CNA B never confirmed or denied fully letting go of the gait belt secured around the resident or assisting CNA A. CNA B said after LVN C assessed Resident #1, CNA A and CNA B rolled Resident #1 from the right to left side to place the mechanical lift sling underneath Resident #1. CNA B said Resident #1 did not complain of pain, she just looked scared. CNA B stated she left to return to her assigned hall while CNA A and LVN C transported Resident #1 to her room via the mechanical lift. Review of CNA A and CNA B training records, both received new hire training, evaluation, and were checked off for appropriate transfer techniques during new hire orientation. Review of recent training documentation, CNA B was recently checked off for transfer techniques on 05/09/2022. During an interview on 05/12/2022 at 1:32 PM and review of DON's progress notes dated 04/20/2022, revealed Ortho MD referral was forwarded to several Ortho MD's but unable to schedule a follow up appt due to insurance. When asked about what interventions put in place, such as Hip Precautions to decrease pain during direct care and prevent further injury, the DON could not corroborate alternative measures implemented in addition to PRN pain medication. The DON indicated that movement may have contributed to the pain when performing incontinence care. Review of the MAR indicated pain medications were administered as needed to Resident #1 to manage pain during the time the facility was actively attempting to schedule a follow up appointment with an Orthopedic MD. The DON indicated Resident #1 was a two-person transfer and every CNA is responsible for reviewing the resident's Kardex (plan of care) before performing direct care or transferring a resident to ensure safety. The DON said she was not present during actual incident but was informed by phone on the evening of 4/15/2022 that Resident #1 was transferred to the hospital for a hip fracture. The DON stated that she was unclear on the cause of the fracture. The DON stated all nursing staff were in-serviced on proper transfer techniques, reporting incidents, and completing incident reports. Handouts were given to all staff on Safe Patient Handling and Moving Protocol and Incidents and Accidents. The DON reported the facility was currently conducting an all-staff skill check off the week of 05/09/2022. During an interview on 05/12/2022 at 2:54 PM, the ADM stated that it is was the facility policy that staff were responsible for looking on the Kardex, transfer list, or asking the charge nurse to know the transfer capabilities of residents on their halls. The policy was intended to prevent harm, injury to, and for patient and staff safety. The ADM said the concern with staff not completing proper transfers with residents was that they could be harmed. Leadership conducts daily rounds making safety and entrapment observations to ensure appropriate steps and proper procedure is are followed when transferring residents. The Inservice Training Report dated 04/18/2022 revealed a summary of the training session for appropriate transfer techniques, reporting, and completing incident reports, including handouts. A review of the facility's Accidents/Incidents Policy and Procedure reflected: An Accident/Incident Report must be completed immediately upon Facility staff becoming aware of the occurrence of an accident/incident . involving a patient . A Head-to-Toe Assessment must be performed at the time .

Based on interview and record review, the facility failed to immediately inform the family and physcian for one (Resident #1) of 15 residents reviewed for change of condition notifications. 1. Staff failed to properly assess and recognize a change in condition to Resident 1'spressure ulcer. Resident #1 had skin abrasion on [DATE] that developed into a Stage II pressure ulcer on [DATE]. Resident was sent to the hospital with a change in condition. Resident #1 was treated for [REDACTED]. Resident #1 expired due [MEDICAL CONDITION] infection [DATE]. 2. Staff failed to recognize and intervene when there was significant size increase and possible infection to Resident #1's pressure ulcer. LVN C failed to notify the DON the Physician and the family when the pressure ulcer deteriorated. This failure affected one resident and placed 94 residents at risk of their family members and/or interested parties and physcian of not being aware of changes in conditions requiring interventions, and not being able to have input into the decisions. Findings included: 1. Review of Resident #1 face sheet reflected resident was an [AGE] year-old-male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's care plan dated [DATE] revealed resident had a [DEVICE], bedfast and required extensive assistance with ADLs. Resident was at risk for pressure ulcers; interventions included daily observation of skin with routine care, full skin evaluation weekly with bath/shower, float heels on pillow, use pillows or other supportive devices to assist with positioning and avoid restrictive clothing; resident was at risk for skin breakdown due to left sided [MEDICAL CONDITION]; interventions included resident was to be provided with pressure reducing surfaces on bed and chair, assistance with position changes and skin was to be kept clean and dry and avoid shearing/friction; [DATE] resident had an abrasion to left buttocks; interventions included treatment was to be followed by physician as ordered, weekly evaluation of wound healing to be completed, daily observation of skin with routine care, full skin evaluation weekly with bath/shower, adjustment of treatment if not healing within ,[DATE] weeks, provide family with progress report of healing status and prompt attention to incontinent episodes. Review of Resident #1 Braden Risk dated [DATE] revealed Resident #1 received a score of 10 which indicated high risk for pressure ulcers. Resident had limited mobility, required maximum assistance, and frequent repositioning. Resident #1 had limited pain perception. Resident #1's Nurse's Notes dated [DATE] and timed at 11:12PM reflected the resident had an open area to his left buttock. The area was cleaned with normal saline, dried and left open to air. The NP was notified. Family notified with no response. Interview with LVN E on [DATE] at 2:18 PM revealed on [DATE] she was called into Resident #1's room by the CNA. LVN E stated Resident #1 had an abrasion/skin tear to his left buttock. LVN E stated she notified the nurse practitioner and left a message for the family and the treatment nurse regarding the abrasion. Review of Resident #1's Wound Assessment Report, dated [DATE] and completed by LVN A, revealed an abrasion measuring 1.50 cm in length by 2.00 cm in width on his left buttocks related to moisture associated damage. There were no signs or symptoms of an infection. (Note: this is the only Wound Assessment Report completed for Resident #1.) Resident #1's undated physician's orders [REDACTED]. Exuderm (is a used to cover the wound) every 3 days and PRN. Resident #1 ' s [DATE] TAR reflected an entry dated [DATE] to clean area to left buttock with Normal saline, pat dry, apply sure prep to peri-wound, apply puracol AG, then cover with Exuderm dressing every 3 days and PRN. The treatment was completed on [DATE], [DATE] and [DATE]. Resident #1 ' s Nurse's Notes dated [DATE] and timed at 12:30 PM reflected an abrasion to his left buttock related to moisture associated damage. Interview with LVN A on [DATE] at 12:06 AM revealed she was the former treatment nurse. LVN A stated LVN B is the new treatment nurse. LVN B stated during the transition period LVN B did not want to perform the wound care treatments, therefore delegating the treatments to floor nurse. LVN A stated she initially measured Resident #1's wound on [DATE], and at that time it was a small skin tear. (Note: Resident #1's Wound Assessment Report, dated [DATE] reflected an abrasion measuring 1.50 cm in length by 2.00 cm in width on his left buttocks). Resident #1's Nurse's Notes, dated [DATE] and timed at 7:04 PM reflected the dressing to his was wound clean dry and intact. Interview with LVN C on [DATE] at 11:49 AM revealed she completed wound care treatment for [REDACTED]. LVN C stated at that time the wound was not too bad. LVN C explained the wound did not have an odor at that time. LVN C stated she provided the treatment per the physician's orders [REDACTED]. LVN C stated she did not document the measurements or appearance of the wound because that was the treatment nurse's job. LVN C did not describe the wound. Interview with LVN C on [DATE] at 11:46 AM revealed she provided wound care on to Resident #1 in the beginning. LVN C stated when she provided wound care on [DATE] she observed Resident #1's wound was bigger and more spread out. She revealed she continued to follow the physician's orders [REDACTED]. LVN C stated she did not notify anyone the wound appeared to have changed and become larger in size. LVN C stated there was no odor or drainage to the wound when she provided the treatment. She revealed Resident #1 had an elevated temperature with some chest congestion during this time. LVN C stated she contacted the physician who ordered a chest x-ray for possible pneumonia and [MEDICATION NAME] for chest congestion. LVN C stated the x-ray came back negative for pneumonia. She revealed once pneumonia was ruled out she did not look into any other causes on why Resident #1 had an elevated temperature. LVN C stated an elevated temperature was a sign of an infection. LVN C stated in hindsight she should have notified the physician, DON or treatment nurse that Resident #1's wound appeared worse and the resident showed signs of an infection. LVN C stated she was following physician orders [REDACTED]. Interview with LVN E on [DATE] at 2:18 PM revealed when she returned to work on [DATE] she provided the wound treatment to Resident #1 as ordered. LVN E stated at that time she noticed the wound appeared larger in size. Resident #1's Nurse's Notes, dated [DATE] and timed at 9:36 PM written by LVN D reflected the resident had a temperature of 101.1 and Tylenol was administered. The physician was not notified at this time according to nurse's note. Resident #1's Nurse's Notes, dated [DATE] and timed at 5:14AM LVN X reflected a temperature of 97.9. Resident #1's Nurse's Notes, dated [DATE] and timed at 2:16 PM written by LVN C reflected he had a temperature of 99.7 and Tylenol was administered. Resident #1's Nurse's Notes, dated [DATE] and timed at 9:51 PM written by LVN D reflected the NP was in the building and assessed the resident. Orders were given for a chest x-ray, [MEDICATION NAME] 1200 mg (cough suppressant), and [MEDICATION NAME] (a sterile inhalation solution containing a combination of [MEDICATION NAME] and [MEDICATION NAME]. [MEDICATION NAME] and [MEDICATION NAME] are [MEDICATION NAME][MEDICATION NAME] that relax muscles in the airways and increase air flow to the lungs) every 6 hours for 5 days while awake. No evidence that physician or NP was promoted by nurses to assess Resident #1. Interview with LVN D on [DATE] at 3:33 PM revealed she provided care to Resident #1. LVN D stated when she provided wound care treatment to Resident #1 on [DATE] she observed eschar. LVN D stated Resident #1's wound appeared to have gotten worse at which time she notified LVN A and the DON. LVN D stated she remembered Resident #1 receiving a pressure relieving mattress that night. Interview with LVN A on [DATE] at 12:06 AM revealed she measured the wound on [DATE] and the wound measured 7.0 cm by 11.0 cm. (Note: Resident #1's Wound Assessment Report, dated [DATE], revealed a measurement of 1.50 cm in length by 2.00 cm in width.) LVN A stated the wound was unstageable with eschar. LVN A stated the wound was not deep. Resident #1's physician's orders [REDACTED]. The order reflected to start cleansing area to left buttock with normal saline, pat dry, apply sureprep (skin protectant) to peri wound, apply puralol AG (collagen based wound dressing) the cover with dry dressing daily and PRN. Resident #1's Nurse's Notes, dated [DATE] and timed at 2:44 PM by LVN C reflected he had a temperature of 99.9 and Tylenol was administered. The dressing to his sacrum was changed as ordered. The note reflected no measurements or description of the wound. Resident #1's [DATE] TAR reflected an entry dated [DATE] to cleanse the area to left buttock with normal saline, pat dry, apply sureprep to peri wound, apply puralol AG the cover with dry dressing daily and PRN. The treatment was completed on [DATE]. Review of Resident #1's dietician note dated [DATE] at 3:29 PM revealed the resident had a Stage II area. Interview with LVN B on [DATE] at 9:40 AM revealed LVN B stated she became the facility treatment nurse on [DATE] during the transition period between treatment nurses the floor nurses were completing wound care on the residents. LVN B stated LVN A became the MDS Coordinator on [DATE] and during the time period between when she became the treatment nurse on [DATE] the floor nurses were providing wound treatments. Interview with LVN B on [DATE] at 11:30 AM revealed she observed Resident #1's wound on [DATE] at which time new treatment orders were received from the physician which included an antibiotic, Bactrim to treat infection of wound. LVN B stated the wound did not have an odor. The wound had slough in it. Resident #1's Nurse's Notes, dated [DATE] and untimed completed by LVN B reflected, This nurse assess open area to resident's sacrum. Odor noted to area and slough, eschar 8x12 noted to open area, wound bed. No pain, drainage present at this time. No dressing noted due to CNA has provided incontinent care. new order to cleanse are with ns (normal saline), pat dry apply sure prep to peri wound, then apply Santyl to wound bed with moist gauze and cover with [MEDICATION NAME] dressing daily. Dressing completed per orders. Notified DON of wound care and wound area due to appearance. Informed charge nurse to notify MD of odor and obtain labs and possible antibiotic for wound. Charge nurse voiced understanding. Resident #1's Nurse's Note, dated [DATE] at 11:04 AM by LVN C , reflected the resident's temperature was 97.6. Resident #1's Nurse's Note, dated [DATE] and timed at 1:09 PM by LVN D reflected the resident was given initial dose of Bactrim ds from ekit with NARN (no adverse reactions noted) Dressing to sacrum clean dry and intact. Resident #1's physician's orders [REDACTED]. Resident #1's physician's orders [REDACTED]. Start: cleanse area to sacrum with normal saline, pat dry apply sureprep (skin protectant) to peri wound, then apply bandage to wound bed (nickel thick) and moist gauze, cover, [MEDICATION NAME] dressing (non-Adhesive is ideal for partial and shallow full-thickness wounds with drainage) daily and PRN. Resident #1's [DATE] TAR reflected an entry dated [DATE], which was to cleanse the area to his sacrum with normal saline, pat dry, apply sureprep to peri wound, then apply bandage to wound bed (nickel thick) and moist gauze, cover, [MEDICATION NAME] dressing daily and PRN. Treatment completed on [DATE] LVN B. Resident #1's Complete Blood Count laboratory results, dated [DATE], reflected an elevated white blood count of 9.2 on [DATE] to 19.5 on [DATE], which indicated a possible infection. Interview with CNA H on [DATE] at 10:30 AM revealed Resident #1's wound started out as a small skin tear. CNA H stated she observed the same area approximately a week later when assisting the nurse with care at that time the wound was the size of her hand. CNA H stated this occurred because Resident #1's brief had not been changed routinely by the other aides for several days. CNA H stated normally Resident #1 received incontinent care at least 3X per shift. Interview with LVN B on [DATE] at 8:15 AM revealed LVN B explained Resident #1 did have an abrasion to his buttocks. LVN B stated the blister came off of the abrasion and the wound developed into a Stage II pressure ulcer. LVN B stated when it was discovered the abrasion had gotten worse and developed into a pressure ulcer, the treatment orders were changed at that time. LVN B stated Resident #1 was sent out to the hospital at the family ' s request after the family observed Resident #1 had difficulty breathing and the wound appeared too had gotten larger. LVN B stated when she observed the wound on [DATE] the wound had slough in it, the treatment orders were changed again and Resident #1 was placed on an antibiotic. Interview with LVN E on [DATE] at 2:18 PM revealed when she came to work on [DATE] the outgoing nurse reported Resident #1 was having difficulty breathing. LVN E stated she administered a breathing treatment to Resident #1. LVN E stated Resident #1's family was in the room when she administered the breathing treatment and provided wound care. LVN E stated when she provided the treatment; the wound appeared to have gotten worse. LVN E stated the family member commented that the wound was larger in size. LVN E stated the family member stated he/she wanted Resident #1 sent to the hospital for further evaluation due to shortness of breath and wound appeared to have gotten worse. LVN E stated she notified her supervisor of the family's request. LVN E described the wound as having zero odor or drainage. The surrounding tissue as slough and the middle pinkish with zero eschar. LVN E stated when she initially saw the wound it was a skin tear and when she saw it the last time on [DATE] it had developed into a pressure ulcer. LVN E stated she did not recall if Resident #1 had a fever. LVN E stated she had received training in school over wound care and had in-services over wound care. Resident #1's physician's orders [REDACTED]. Review of Resident #1 hospital admission nurse's note dated [DATE] revealed resident was admitted to the hospital on [DATE] due to shortness of breath, abdominal pain and diarrhea. Hospital nurses' note dated [DATE] reflected Resident #1 had a stage II decubitus pressure ulcer to sacrum upon admission. Review of Resident #1 hospital history and physical assessment dated [DATE] revealed Resident #1 was found to have leukocytosis (increased white blood cell count due to infection), [MEDICAL CONDITION](increased heart rate) and [MEDICAL CONDITION] requiring admission to MICU (Medical Intensive Care Unit). [MEDICAL CONDITION] from stage II decubitus ulcer. Review of Resident #1 hospital death pronouncement note dated [DATE] revealed Resident #1 expired on [DATE] at 9:24 PM. Resident found to have [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interview with family member on [DATE] at 9:00 AM revealed family member stated they were notified by the physician at the local hospital that Resident #1 died due to an infection of the wound. Resident #1's Nurse's Note, dated [DATE] completed by LVN B, reflected, This nurse notified by weekend supervisor on [DATE] of resident d/c to ER due to shortness of breath and wound care concerns from family member. Informed weekend supervisor that this nurse notify family member of all wound care orders and lab workup and medication regimen. Family member stated Resident #1 was breathing different and his wound had become bigger and family member was concerned. Family member stated he has been wanting him to go to hospital. Review of Pressure Ulcer Prevention Program dated [DATE] revealed if a resident is discovered with skin breakdown or pressure ulcer is identified a licensed nurse will assess the area on a weekly basis to determine progress and modify treatment as appropriate. The resident's physician and family will be notified. The resident's plan of care will be updated. Review of Significant Change and Physician Notification policy (not dated) revealed a resident's family or legal representative and physician are notified when a resident has a significant change in physical, mental or psychosocial status. Examples of significant change include development of pressure sore, elevated temperature, abrupt onset of shortness of breath, abnormal lab results and new wounds or bruises. Administrator was notified of Immediate Jeopardy on [DATE] at 10:00 AM, Administrator voiced understanding of Immediate Threat and a Plan of Removal was requested at this time. The Plan of Removal was accepted on [DATE] 4:11 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance, due to the facility was still monitoring the effectiveness of the Plan of Removal. PLAN OF REMOVAL: Actions implemented by facility: Assessment: A complete head to toe skin sweep was initiated using body diagram sheets (if pressure noted then a pressure ulcer assessment form was utilized and if non pressure noted then a non-pressure assessment form was utilized) on [DATE] and continued through [DATE] completed by corporate wound care nurse, DON, LVN B, ADON, LVN A on [DATE] and a secondary sweep was completed by corporate nursing staff with an end date [DATE]. This included updated assessments which includes pressure and non-pressure assessments; appropriate documentation such as; treatment orders if indicated, notification of MD/ family, care plans updated. The facility did not have a failure in documentation, due the existence in the medical records of assessment orders and care plans. We are incorporating all of the required skin and wound care documentation in our retraining. The skin and wound care documentation will consist of Braden Scale, care planning for skin risk, weekly head to toe skin checks documentation, pressure and non-pressure ulcer assessments, and how to write telephone orders. Reassessment was done using the skin condition record forms(see attached) of current wounds by certified wound nurse, to include current measurements and staging as well as any required treatment changes was started and completed on [DATE] has not ever provided care to this resident. Findings included issues with 3 residents which are broken out as follows: 1 DTI, 5 Stage II and 2 Arterial. Physicians and families were notified for the 3 residents (Resident #9, #11 and #13) on [DATE] by ADON. Care plans were started on [DATE] and completed on [DATE] by corporate nurses. In-services/Training/Competency Validation: On [DATE] an In-service was initiated and completed for nursing administration by certified wound nurse on the following: Head to Toe assessments; correct staging of wounds; correct measuring of wounds; proper positioning; identifying new skin issues; reporting changes in skin issues; Competency will be tested via skills check off headed by certified wound care nurse. Nursing Administration will also be inserviced on therapeutic support surface protocol that includes bottoming out test to determine setting, posting of setting as well as documentation for monitoring of function and setting. In-service was initiated and completed on [DATE] by Certified Wound Therapist who provides support to facilities and has never provided care to this resident. For all remaining staff including weekend, PRN, on leave, DON and Administrator will monitor to ensure remaining receive in-service/training/competency prior to working on the floor. In-service for nursing on the following topics was started [DATE] and completed [DATE] by DON on the following topics: Head to Toe assessments; correct staging of wounds; correct measuring of wounds; proper positioning; identifying new skin issues; reporting changes in skin issues and documentation of family notification. DON has not provided direct care to this resident. Nursing will also be inserviced on therapeutic support surface protocol that includes bottoming out test to determine setting, posting of setting as well as documentation for monitoring of function and setting. This will be started [DATE] and completed on [DATE] DON and/or RCS. DON and RCS have not provided direct care to this resident. No licensed nurse will be permitted to work their scheduled shift without this in-service. All efforts will be made to capture all staff including weekend staff but no staff will be allowed to work until completed. Competency will be tested via skills check off headed by DON and/or RCS. For all remaining staff including weekend, PRN, on leave, DON and Administrator will monitor to ensure remaining receive in-service/training/competency prior to working on the floor. In-service for certified nursing assistants will be completed by DON and/or RCS on positioning and turning at least Q2 hours and more frequently if indicated per the plan of care. The facility will implement a shower sheet for the CNA's to use to mark any skin concerns that they observe. The sheets will be turned into the charge nurse for further assessment and follow up. The sheets will be immediately turned into the charge nurse. They will also be trained to immediately notify their licensed nurse of any skin concerns that they observe. Once skin concern is identified the charge nurse will immediately complete an assessment of the area, obtain treatment orders and notify his facility IDT team i.e. treatment nurse and DON. In-service will be started on [DATE] and completed on [DATE]. No CNAs, PRN or weekend staff will be allowed to work their scheduled shift until they complete the in-service. For all remaining staff including weekend, PRN, on leave, DON and Administrator will monitor to ensure remaining receive in-service/training/competency prior to working on the floor. Skin and wound training will be incorporated into the licensed nurse orientation effective [DATE] and will be conducted by DON. This will ensure that all new hires are being trained prior to working the floor. Monitoring and compliance will be provided by Administrator. Certified wound nurse will come measure and stage all wounds weekly for four weeks until present treatment nurse, LVN B has been deemed competent in staging and assessment which will include supervised dressing changes and wound assessment with return demonstration and skills validation as identified by peer reviewer. Once a wound is identified by LVN B her process is: After initial assessment, orders and notification per protocol she will monitor during provision of wound care and weekly head to toe skin checks. For the next four weeks she will have a peer reviewer who is certified in wound care to validate staging and assessment of wounds. If a wound gets worse, her steps will be: If a wound is noted to get worse the facility will immediately notify physician and family, as well as implement update treatment plan that may include hospitalization if indicated or if deemed necessary by attending physician. Monitoring: Facility will implement weekly wound rounds by interdisciplinary team [DATE]. The team will be composed of a PT, DON and Treatment Nurse. These rounds will enable nursing administration to have oversight of wound care and ensure that staffing is appropriate and resident wounds are progressing as per plans of care. Weekly head to toe skin checks will be completed weekly by Nursing Administration to include ADON and DON for four weeks then monthly thereafter. Any issues identified will be immediately corrected by nursing administration and/or treatment nurse. Residents noted to acquire pressure ulcers in the facility will have a root cause analysis performed to identify cause or contributing factors, as well as implement preventative solutions by DON. All findings will be reported to the QAPI committee consisting of Administrator, DON, LVN B and ADON. Medical Director Notification and Involvement: DON contacted Medical Director and notified him of the Immediate Jeopardy on [DATE]. Overall Responsibility for Plan of Removal: Administrator will monitor this plan of removal to ensure all tasks will be completed. Review of results of facility skin sweep completed [DATE] revealed facility completed skin assessment on all residents, identifying and assessing all skin issues, ensuring proper treatments and updating care plans to reflect treatment. Review of the In-service Agenda revealed all of the items identified in the Plan of Removal were addressed. In-services included: Distinguishing deep tissue injuries from other skin issues, Identifying bottoming out and setting of the low air loss mattress, head to toe assessment on admission and readmission, staging and measuring wounds, wound documentation, weekly skin assessments/wound reporting, prevention and Management of Pressure Ulcers-Evidence Based Best Practice, shower sheets, reporting skin issues, preventative care for residents at risk for wounds and proficiency checks involved wound assessment and wound care. Following the acceptance of the plan of removal on [DATE], monitoring of in-service documents, attendance rosters, proficiency check lists and interview of staff representing all shifts was completed. Staff members were asked about the in-services they attended, what they learned, what the overall purpose of the in-services was, how it applied to them, did it change their practice? and the impact on the facility. Staff interviewed on various shifts included: LVN F, CNA B, LVN G, LVN C, CNA H, CNA I, CNA J, CNA P, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, LVN B, LVN M, LVN N LVN O. RN K, RA L, DON and the Administrator. All staff were able to articulate the in-service material and expressed varying thoughts on what they took away from the educational opportunities. They all identified a renewed focus on basic care, wound prevention, identification and early reporting. One CNA expressed it well; if you can see it, report it. The Immediate Jeopardy was removed on [DATE] at 4:11 PM; the facility remained out of compliance due to continued monitoring of the effectiveness of the Plan of Removal. Census dated [DATE] reflected a census of 94 residents.

Based on observation, interview and record review it was determined the facility failed to ensure the resident's right to be free from neglect for one (Resident #1) of 15 residents reviewed for neglect. 1. Staff failed to properly assess and recognize a change in condition to Resident 1's pressure ulcer. Resident #1 had skin abrasion on [DATE] that developed into a stage II pressure ulcer on [DATE]. Resident was sent to the hospital with a change in condition. Resident #1 was treated for [REDACTED]. 2. Staff failed to recognize and intervene when there was significant size increase and possible infection to Resident #1's pressure ulcer. LVN C failed to notify the DON and the Physician when the wound deteriorated. 3. Facility failed to identify a change in condition to Resident's #1's wound when the wound began to deteriorate. On [DATE] the pressure ulcer measured 1.50 cm by 2.0 cm, and on [DATE] the wound measured 8.0 cm by 12.0 cm. The facility's protocol required weekly wound assessment, which failed to identify the rapid deterioration of Resident's #1's wound. Facility's failure to properly assess and recognize deterioration of Resident #1's wound resulted in resident being admitted to the hospital with [REDACTED]. Resident expired on [DATE] as a result [MEDICAL CONDITION] to infected wound. An Immediate Jeopardy (IJ) was identified on [DATE] at 10:00 AM. While the IJ was removed on [DATE], the facility remained out of compliance, due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect 65 residents, who are identified on the Pressure Ulcer Risk Report as mild to high risk for the development of pressure ulcers by placing them at risk for skin breakdown and development of pressure ulcers, pain and discomfort, which could result in osteo[DIAGNOSES REDACTED] (infection of the bone),[MEDICAL CONDITION] (infection of the blood), untreated skin problems and/or death. 1. Review of Resident #1 face sheet reflected resident was an [AGE] year-old-male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's care plan dated [DATE] revealed resident had a [DEVICE], bedfast and required extensive assistance with ADLs. Resident was at risk for pressure ulcers; interventions included daily observation of skin with routine care, full skin evaluation weekly with bath/shower, float heels on pillow, use pillows or other supportive devices to assist with positioning and avoid restrictive clothing; resident was at risk for skin breakdown due to left sided [MEDICAL CONDITION]; interventions included resident was to be provided with pressure reducing surfaces on bed and chair, assistance with position changes and skin was to be kept clean and dry and avoid shearing/friction; [DATE] resident had an abrasion to left buttocks; interventions included treatment was to be followed by physician as ordered, weekly evaluation of wound healing to be completed, daily observation of skin with routine care, full skin evaluation weekly with bath/shower, adjustment of treatment if not healing within ,[DATE] weeks, provide family with progress report of healing status and prompt attention to incontinent episodes. Review of Resident #1 Braden Risk dated [DATE] revealed Resident #1 received a score of 10 which indicated high risk for pressure ulcers. Resident had limited mobility, required maximum assistance, and frequent repositioning. Resident #1 had limited pain perception. Resident #1's Nurse's Notes dated [DATE] and timed at 11:12PM reflected the resident had an open area to his left buttock. The area was cleaned with normal saline, dried and left open to air. The NP was notified. Family notified with no response. Interview with LVN E on [DATE] at 2:18 PM revealed on [DATE] she was called into Resident #1's room by the CNA. LVN E stated Resident #1 had an abrasion/skin tear to his left buttock. LVN E stated she notified the nurse practitioner and left a message for the family and the treatment nurse regarding the abrasion. Review of Resident #1's Wound Assessment Report, dated [DATE] and completed by LVN A, revealed an abrasion measuring 1.50 cm in length by 2.00 cm in width on his left buttocks related to moisture associated damage. There were no signs or symptoms of an infection. (Note: this is the only Wound Assessment Report completed for Resident #1.) Resident #1's undated physician's orders [REDACTED]. Exuderm (is a used to cover the wound) every 3 days and PRN. Resident #1's [DATE] TAR reflected an entry dated [DATE] to clean area to left buttock with Normal saline, pat dry, apply sure prep to peri-wound, apply puracol AG, then cover with Exuderm dressing every 3 days and PRN. The treatment was completed on [DATE], [DATE] and [DATE]. Resident #1 ' s Nurse's Notes dated [DATE] and timed at 12:30 PM reflected an abrasion to his left buttock related to moisture associated damage. Interview with LVN A on [DATE] at 12:06 AM revealed she was the former treatment nurse. LVN A stated LVN B is the new treatment nurse. LVN B stated during the transition period LVN B did not want to perform the wound care treatments, therefore delegating the treatments to floor nurse. LVN A stated she initially measured Resident #1's wound on [DATE], and at that time it was a small skin tear. (Note: Resident #1's Wound Assessment Report, dated [DATE] reflected an abrasion measuring 1.50 cm in length by 2.00 cm in width on his left buttocks). Resident #1's Nurse's Notes, dated [DATE] and timed at 7:04 PM reflected the dressing to his was wound clean dry and intact. Interview with LVN C on [DATE] at 11:49 AM revealed she completed wound care treatment for [REDACTED]. LVN C stated at that time the wound was not too bad. LVN C explained the wound did not have an odor at that time. LVN C stated she provided the treatment per the physician's orders [REDACTED]. LVN C stated she did not document the measurements or appearance of the wound because that was the treatment nurse's job. LVN C did not describe the wound. Interview with LVN C on [DATE] at 11:46 AM revealed she provided wound care on to Resident #1 in the beginning. LVN C stated when she provided wound care on [DATE] she observed Resident #1's wound was bigger and more spread out. She revealed she continued to follow the physician's orders [REDACTED]. LVN C stated she did not notify anyone the wound appeared to have changed and become larger in size. LVN C stated there was no odor or drainage to the wound when she provided the treatment. She revealed Resident #1 had an elevated temperature with some chest congestion during this time. LVN C stated she contacted the physician who ordered a chest x-ray for possible pneumonia and [MEDICATION NAME] for chest congestion. LVN C stated the x-ray came back negative for pneumonia. She revealed once pneumonia was ruled out she did not look into any other causes on why Resident #1 had an elevated temperature. LVN C stated an elevated temperature was a sign of an infection. LVN C stated in hindsight she should have notified the physician, DON or treatment nurse that Resident #1's wound appeared worse and the resident showed signs of an infection. LVN C stated she was following physician orders [REDACTED]. Interview with LVN E on [DATE] at 2:18 PM revealed when she returned to work on [DATE] she provided the wound treatment to Resident #1 as ordered. LVN E stated at that time she noticed the wound appeared larger in size. Resident #1's Nurse's Notes, dated [DATE] and timed at 9:36 PM written by LVN D reflected the resident had a temperature of 101.1 and Tylenol was administered. The physician was not notified at this time according to nurse's note. Resident #1's Nurse's Notes, dated [DATE] and timed at 5:14AM LVN X reflected a temperature of 97.9. Resident #1's Nurse's Notes, dated [DATE] and timed at 2:16 PM written by LVN C reflected he had a temperature of 99.7 and Tylenol was administered. Resident #1's Nurse's Notes, dated [DATE] and timed at 9:51 PM written by LVN D reflected the NP was in the building and assessed the resident. Orders were given for a chest x-ray, [MEDICATION NAME] 1200 mg (cough suppressant), and [MEDICATION NAME] (a sterile inhalation solution containing a combination of [MEDICATION NAME] and [MEDICATION NAME]. [MEDICATION NAME] and [MEDICATION NAME] are [MEDICATION NAME][MEDICATION NAME] that relax muscles in the airways and increase air flow to the lungs) every 6 hours for 5 days while awake. No evidence that physician or NP was promoted by nurses to assess Resident #1. Interview with LVN D on [DATE] at 3:33 PM revealed she provided care to Resident #1. LVN D stated when she provided wound care treatment to Resident #1 on [DATE] she observed eschar. LVN D stated Resident #1's wound appeared to have gotten worse at which time she notified LVN A and the DON. LVN D stated she remembered Resident #1 receiving a pressure relieving mattress that night. Interview with LVN A on [DATE] at 12:06 AM revealed she measured the wound on [DATE] and the wound measured 7.0 cm by 11.0 cm. (Note: Resident #1's Wound Assessment Report, dated [DATE], revealed a measurement of 1.50 cm in length by 2.00 cm in width.) LVN A stated the wound was unstageable with eschar. LVN A stated the wound was not deep. Resident #1's physician's orders [REDACTED]. The order reflected to start cleansing area to left buttock with normal saline, pat dry, apply sureprep (skin protectant) to peri wound, apply puralol AG (collagen based wound dressing) the cover with dry dressing daily and PRN. Resident #1's Nurse's Notes, dated [DATE] and timed at 2:44 PM by LVN C reflected he had a temperature of 99.9 and Tylenol was administered. The dressing to his sacrum was changed as ordered. The note reflected no measurements or description of the wound. Resident #1's [DATE] TAR reflected an entry dated [DATE] to cleanse the area to left buttock with normal saline, pat dry, apply sureprep to peri wound, apply puralol AG the cover with dry dressing daily and PRN. The treatment was completed on [DATE]. Review of Resident #1's dietician note dated [DATE] at 3:29 PM revealed the resident had a Stage II area. Interview with LVN B on [DATE] at 9:40 AM revealed LVN B stated she became the facility treatment nurse on [DATE] during the transition period between treatment nurses the floor nurses were completing wound care on the residents. LVN B stated LVN A became the MDS Coordinator on [DATE] and during the time period between when she became the treatment nurse on [DATE] the floor nurses were providing wound treatments. Interview with LVN B on [DATE] at 11:30 AM revealed she observed Resident #1's wound on [DATE] at which time new treatment orders were received from the physician which included an antibiotic, Bactrim to treat infection of wound. LVN B stated the wound did not have an odor. The wound had slough in it. Resident #1's Nurse's Notes, dated [DATE] and untimed completed by LVN B reflected, This nurse assess open area to resident's sacrum. Odor noted to area and slough, eschar 8x12 noted to open area, wound bed. No pain, drainage present at this time. No dressing noted due to CNA has provided incontinent care. new order to cleanse are with ns (normal saline), pat dry apply sure prep to peri wound, then apply Santyl to wound bed with moist gauze and cover with [MEDICATION NAME] dressing daily. Dressing completed per orders. Notified DON of wound care and wound area due to appearance. Informed charge nurse to notify MD of odor and obtain labs and possible antibiotic for wound. Charge nurse voiced understanding. Resident #1's Nurse's Note, dated [DATE] at 11:04 AM by LVN C , reflected the resident's temperature was 97.6. Resident #1's Nurse's Note, dated [DATE] and timed at 1:09 PM by LVN D reflected the resident was given initial dose of Bactrim ds from ekit with NARN (no adverse reactions noted) Dressing to sacrum clean dry and intact. Resident #1's physician's orders [REDACTED]. Resident #1's physician's orders [REDACTED]. Start: cleanse area to sacrum with normal saline, pat dry apply sureprep (skin protectant) to peri wound, then apply bandage to wound bed (nickel thick) and moist gauze, cover, [MEDICATION NAME] dressing (non-Adhesive is ideal for partial and shallow full-thickness wounds with drainage) daily and PRN. Resident #1's [DATE] TAR reflected an entry dated [DATE], which was to cleanse the area to his sacrum with normal saline, pat dry, apply sureprep to peri wound, then apply bandage to wound bed (nickel thick) and moist gauze, cover, [MEDICATION NAME] dressing daily and PRN. Treatment completed on [DATE] LVN B. Resident #1's Complete Blood Count laboratory results, dated [DATE], reflected an elevated white blood count of 9.2 on [DATE] to 19.5 on [DATE], which indicated a possible infection. Interview with CNA H on [DATE] at 10:30 AM revealed Resident #1's wound started out as a small skin tear. CNA H stated she observed the same area approximately a week later when assisting the nurse with care at that time the wound was the size of her hand. CNA H stated this occurred because Resident #1's brief had not been changed routinely by the other aides for several days. CNA H stated normally Resident #1 received incontinent care at least 3X per shift. Interview with LVN B on [DATE] at 8:15 AM revealed LVN B explained Resident #1 did have an abrasion to his buttocks. LVN B stated the blister came off of the abrasion and the wound developed into a Stage II pressure ulcer. LVN B stated when it was discovered the abrasion had gotten worse and developed into a pressure ulcer, the treatment orders were changed at that time. LVN B stated Resident #1 was sent out to the hospital at the family ' s request after the family observed Resident #1 had difficulty breathing and the wound appeared too had gotten larger. LVN B stated when she observed the wound on [DATE] the wound had slough in it, the treatment orders were changed again and Resident #1 was placed on an antibiotic. Interview with LVN E on [DATE] at 2:18 PM revealed when she came to work on [DATE] the outgoing nurse reported Resident #1 was having difficulty breathing. LVN E stated she administered a breathing treatment to Resident #1. LVN E stated Resident #1's family was in the room when she administered the breathing treatment and provided wound care. LVN E stated when she provided the treatment; the wound appeared to have gotten worse. LVN E stated the family member commented that the wound was larger in size. LVN E stated the family member stated he/she wanted Resident #1 sent to the hospital for further evaluation due to shortness of breath and wound appeared to have gotten worse. LVN E stated she notified her supervisor of the family's request. LVN E described the wound as having zero odor or drainage. The surrounding tissue as slough and the middle pinkish with zero eschar. LVN E stated when she initially saw the wound it was a skin tear and when she saw it the last time on [DATE] it had developed into a pressure ulcer. LVN E stated she did not recall if Resident #1 had a fever. LVN E stated she had received training in school over wound care and had in-services over wound care. Resident #1's physician's orders [REDACTED]. Review of Resident #1 hospital admission nurse's note dated [DATE] revealed resident was admitted to the hospital on [DATE] due to shortness of breath, abdominal pain and diarrhea. Hospital nurses' note dated [DATE] reflected Resident #1 had a stage II decubitus pressure ulcer to sacrum upon admission. Review of Resident #1 hospital history and physical assessment dated [DATE] revealed Resident #1 was found to have leukocytosis (increased white blood cell count due to infection), [MEDICAL CONDITION](increased heart rate) and [MEDICAL CONDITION] requiring admission to MICU (Medical Intensive Care Unit). [MEDICAL CONDITION] from stage II decubitus ulcer. Review of Resident #1 hospital death pronouncement note dated [DATE] revealed Resident #1 expired on [DATE] at 9:24 PM. Resident found to have [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interview with family member on [DATE] at 9:00 AM revealed family member stated they were notified by the physician at the local hospital that Resident #1 died due to an infection of the wound. Resident #1's Nurse's Note, dated [DATE] completed by LVN B, reflected, This nurse notified by weekend supervisor on [DATE] of resident d/c to ER due to shortness of breath and wound care concerns from family member. Informed weekend supervisor that this nurse notify family member of all wound care orders and lab workup and medication regimen. Family member stated Resident #1 was breathing different and his wound had become bigger and family member was concerned. Family member stated he has been wanting him to go to hospital. Review of Policy for Prohibition of Abuse, Neglect and Misappropriation of Property dated [DATE] revealed neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish and mental illness. Review of Pressure Ulcer Prevention Program dated [DATE] revealed if a resident is discovered with skin breakdown or pressure ulcer is identified a licensed nurse will assess the area on a weekly basis to determine progress and modify treatment as appropriate. The resident's physician and family will be notified. The resident's plan of care will be updated. Review of Significant Change and Physician Notification policy (not dated) revealed a resident's family or legal representative and physician are notified when a resident has a significant change in physical, mental or psychosocial status. Examples of significant change include development of pressure sore, elevated temperature, abrupt onset of shortness of breath, abnormal lab results and new wounds or bruises. Administrator was notified of Immediate Jeopardy on [DATE] at 10:00 AM, Administrator voiced understanding of Immediate Threat and a Plan of Removal was requested at this time. The Plan of Removal was accepted on [DATE] 4:11 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance, due to the facility was still monitoring the effectiveness of the Plan of Removal. PLAN OF REMOVAL: Actions implemented by facility: Assessment: A complete head to toe skin sweep was initiated using body diagram sheets (if pressure noted then a pressure ulcer assessment form was utilized and if non pressure noted then a non-pressure assessment form was utilized) on [DATE] and continued through [DATE] completed by corporate wound care nurse, DON, LVN B, ADON, LVN A on [DATE] and a secondary sweep was completed by corporate nursing staff with an end date [DATE]. This included updated assessments which includes pressure and non-pressure assessments; appropriate documentation such as; treatment orders if indicated, notification of MD/ family, care plans updated. The facility did not have a failure in documentation, due the existence in the medical records of assessment orders and care plans. We are incorporating all of the required skin and wound care documentation in our retraining. The skin and wound care documentation will consist of Braden Scale, care planning for skin risk, weekly head to toe skin checks documentation, pressure and non-pressure ulcer assessments, and how to write telephone orders. Reassessment was done using the skin condition record forms(see attached) of current wounds by certified wound nurse, to include current measurements and staging as well as any required treatment changes was started and completed on [DATE] has not ever provided care to this resident. Findings included issues with 3 residents which are broken out as follows: 1 DTI, 5 Stage II and 2 Arterial. Physicians and families were notified for the 3 residents (Resident #9, #11 and #13) on [DATE] by ADON. Care plans were started on [DATE] and completed on [DATE] by corporate nurses. In-services/Training/Competency Validation: On [DATE] an In-service was initiated and completed for nursing administration by certified wound nurse on the following: Head to Toe assessments; correct staging of wounds; correct measuring of wounds; proper positioning; identifying new skin issues; reporting changes in skin issues; Competency will be tested via skills check off headed by certified wound care nurse. Nursing Administration will also be inserviced on therapeutic support surface protocol that includes bottoming out test to determine setting, posting of setting as well as documentation for monitoring of function and setting. In-service was initiated and completed on [DATE] by Certified Wound Therapist who provides support to facilities and has never provided care to this resident. For all remaining staff including weekend, PRN, on leave, DON and Administrator will monitor to ensure remaining receive in-service/training/competency prior to working on the floor. In-service for nursing on the following topics was started [DATE] and completed [DATE] by DON on the following topics: Head to Toe assessments; correct staging of wounds; correct measuring of wounds; proper positioning; identifying new skin issues; reporting changes in skin issues and documentation of family notification. DON has not provided direct care to this resident. Nursing will also be inserviced on therapeutic support surface protocol that includes bottoming out test to determine setting, posting of setting as well as documentation for monitoring of function and setting. This will be started [DATE] and completed on [DATE] DON and/or RCS. DON and RCS have not provided direct care to this resident. No licensed nurse will be permitted to work their scheduled shift without this in-service. All efforts will be made to capture all staff including weekend staff but no staff will be allowed to work until completed. Competency will be tested via skills check off headed by DON and/or RCS. For all remaining staff including weekend, PRN, on leave, DON and Administrator will monitor to ensure remaining receive in-service/training/competency prior to working on the floor. In-service for certified nursing assistants will be completed by DON and/or RCS on positioning and turning at least Q2 hours and more frequently if indicated per the plan of care. The facility will implement a shower sheet for the CNA's to use to mark any skin concerns that they observe. The sheets will be turned into the charge nurse for further assessment and follow up. The sheets will be immediately turned into the charge nurse. They will also be trained to immediately notify their licensed nurse of any skin concerns that they observe. Once skin concern is identified the charge nurse will immediately complete an assessment of the area, obtain treatment orders and notify his facility IDT team i.e. treatment nurse and DON. In-service will be started on [DATE] and completed on [DATE]. No CNAs, PRN or weekend staff will be allowed to work their scheduled shift until they complete the in-service. For all remaining staff including weekend, PRN, on leave, DON and Administrator will monitor to ensure remaining receive in-service/training/competency prior to working on the floor. Skin and wound training will be incorporated into the licensed nurse orientation effective [DATE] and will be conducted by DON. This will ensure that all new hires are being trained prior to working the floor. Monitoring and compliance will be provided by Administrator. Certified wound nurse will come measure and stage all wounds weekly for four weeks until present treatment nurse, LVN B has been deemed competent in staging and assessment which will include supervised dressing changes and wound assessment with return demonstration and skills validation as identified by peer reviewer. Once a wound is identified by LVN B her process is: After initial assessment, orders and notification per protocol she will monitor during provision of wound care and weekly head to toe skin checks. For the next four weeks she will have a peer reviewer who is certified in wound care to validate staging and assessment of wounds. If a wound gets worse, her steps will be: If a wound is noted to get worse the facility will immediately notify physician and family, as well as implement update treatment plan that may include hospitalization if indicated or if deemed necessary by attending physician. Monitoring: Facility will implement weekly wound rounds by interdisciplinary team [DATE]. The team will be composed of a PT, DON and Treatment Nurse. These rounds will enable nursing administration to have oversight of wound care and ensure that staffing is appropriate and resident wounds are progressing as per plans of care. Weekly head to toe skin checks will be completed weekly by Nursing Administration to include ADON and DON for four weeks then monthly thereafter. Any issues identified will be immediately corrected by nursing administration and/or treatment nurse. Residents noted to acquire pressure ulcers in the facility will have a root cause analysis performed to identify cause or contributing factors, as well as implement preventative solutions by DON. All findings will be reported to the QAPI committee consisting of Administrator, DON, LVN B and ADON. Medical Director Notification and Involvement: DON contacted Medical Director and notified him of the Immediate Jeopardy on [DATE]. Overall Responsibility for Plan of Removal: Administrator will monitor this plan of removal to ensure all tasks will be completed. Review of results of facility skin sweep completed [DATE] revealed facility completed skin assessment on all residents, identifying and assessing all skin issues, ensuring proper treatments and updating care plans to reflect treatment. Review of the In-service Agenda revealed all of the items identified in the Plan of Removal were addressed. In-services included: Distinguishing deep tissue injuries from other skin issues, Identifying bottoming out and setting of the low air loss mattress, head to toe assessment on admission and readmission, staging and measuring wounds, wound documentation, weekly skin assessments/wound reporting, prevention and Management of Pressure Ulcers-Evidence Based Best Practice, shower sheets, reporting skin issues, preventative care for residents at risk for wounds and proficiency checks involved wound assessment and wound care. Following the acceptance of the plan of removal on [DATE], monitoring of in-service documents, attendance rosters, proficiency check lists and interview of staff representing all shifts was completed. Staff members were asked about the in-services they attended, what they learned, what the overall purpose of the in-services was, how it applied to them, did it change their practice? and the impact on the facility. Staff interviewed on various shifts included: LVN F, CNA B, LVN G, LVN C, CNA H, CNA I, CNA J, CNA P, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, LVN B, LVN M, LVN N LVN O. RN K, RA L, DON and the Administrator. All staff were able to articulate the in-service material and expressed varying thoughts on what they took away from the educational opportunities. They all identified a renewed focus on basic care, wound prevention, identification and early reporting. One CNA expressed it well; if you can see it, report it. The Immediate Jeopardy was removed on [DATE] at 4:11 PM; the facility remained out of compliance due to continued monitoring of the effectiveness of the Plan of Removal. Census dated [DATE] reflected a census of 94 residents.

Based on observation, interview and record review it was determined the facility failed to ensure the resident's right to be free from neglect for one (Resident #1) of 15 residents reviewed for neglect. 1. Staff failed to properly assess and recognize a change in condition to Resident 1's pressure ulcer. Resident #1 had skin abrasion on [DATE] that developed into a stage II pressure ulcer on [DATE]. Resident was sent to the hospital with a change in condition. Resident #1 was treated for [REDACTED]. 2. Staff failed to recognize and intervene when there was significant size increase and possible infection to Resident #1's pressure ulcer. LVN C failed to notify the DON and the Physician when the wound deteriorated. 3. Facility failed to identify a change in condition to Resident's #1's wound when the wound began to deteriorate. On [DATE] the pressure ulcer measured 1.50 cm by 2.0 cm, and on [DATE] the wound measured 8.0 cm by 12.0 cm. The facility's protocol required weekly wound assessment, which failed to identify the rapid deterioration of Resident's #1's wound. Facility's failure to properly assess and recognize deterioration of Resident #1's wound resulted in resident being admitted to the hospital with [REDACTED]. Resident expired on [DATE] as a result [MEDICAL CONDITION] to infected wound. An Immediate Jeopardy (IJ) was identified on [DATE] at 10:00 AM. While the IJ was removed on [DATE], the facility remained out of compliance, due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect 65 residents, who are identified on the Pressure Ulcer Risk Report as mild to high risk for the development of pressure ulcers by placing them at risk for skin breakdown and development of pressure ulcers, pain and discomfort, which could result in osteo[DIAGNOSES REDACTED] (infection of the bone),[MEDICAL CONDITION] (infection of the blood), untreated skin problems and/or death. Review of Policy for Prohibition of Abuse, Neglect and Misappropriation of Property dated [DATE] revealed neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish and mental illness. Review of Pressure Ulcer Prevention Program dated [DATE] revealed if a resident is discovered with skin breakdown or pressure ulcer is identified a licensed nurse will assess the area on a weekly basis to determine progress and modify treatment as appropriate. The resident's physician and family will be notified. The resident's plan of care will be updated. Review of Significant Change and Physician Notification policy (not dated) revealed a resident's family or legal representative and physician are notified when a resident has a significant change in physical, mental or psychosocial status. Examples of significant change include development of pressure sore, elevated temperature, abrupt onset of shortness of breath, abnormal lab results and new wounds or bruises. 1. Review of Resident #1 face sheet reflected resident was an [AGE] year-old-male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's care plan dated [DATE] revealed resident had a [DEVICE], bedfast and required extensive assistance with ADLs. Resident was at risk for pressure ulcers; interventions included daily observation of skin with routine care, full skin evaluation weekly with bath/shower, float heels on pillow, use pillows or other supportive devices to assist with positioning and avoid restrictive clothing; resident was at risk for skin breakdown due to left sided [MEDICAL CONDITION]; interventions included resident was to be provided with pressure reducing surfaces on bed and chair, assistance with position changes and skin was to be kept clean and dry and avoid shearing/friction; [DATE] resident had an abrasion to left buttocks; interventions included treatment was to be followed by physician as ordered, weekly evaluation of wound healing to be completed, daily observation of skin with routine care, full skin evaluation weekly with bath/shower, adjustment of treatment if not healing within ,[DATE] weeks, provide family with progress report of healing status and prompt attention to incontinent episodes. Review of Resident #1 Braden Risk dated [DATE] revealed Resident #1 received a score of 10 which indicated high risk for pressure ulcers. Resident had limited mobility, required maximum assistance, and frequent repositioning. Resident #1 had limited pain perception. Resident #1's Nurse's Notes dated [DATE] and timed at 11:12PM reflected the resident had an open area to his left buttock. The area was cleaned with normal saline, dried and left open to air. The NP was notified. Family notified with no response. Interview with LVN E on [DATE] at 2:18 PM revealed on [DATE] she was called into Resident #1's room by the CNA. LVN E stated Resident #1 had an abrasion/skin tear to his left buttock. LVN E stated she notified the nurse practitioner and left a message for the family and the treatment nurse regarding the abrasion. Review of Resident #1's Wound Assessment Report, dated [DATE] and completed by LVN A, revealed an abrasion measuring 1.50 cm in length by 2.00 cm in width on his left buttocks related to moisture associated damage. There were no signs or symptoms of an infection. (Note: this is the only Wound Assessment Report completed for Resident #1.) Resident #1's undated physician's orders [REDACTED]. Exuderm (is a used to cover the wound) every 3 days and PRN. Resident #1's [DATE] TAR reflected an entry dated [DATE] to clean area to left buttock with Normal saline, pat dry, apply sure prep to peri-wound, apply puracol AG, then cover with Exuderm dressing every 3 days and PRN. The treatment was completed on [DATE], [DATE] and [DATE]. Resident #1 ' s Nurse's Notes dated [DATE] and timed at 12:30 PM reflected an abrasion to his left buttock related to moisture associated damage. Interview with LVN A on [DATE] at 12:06 AM revealed she was the former treatment nurse. LVN A stated LVN B is the new treatment nurse. LVN B stated during the transition period LVN B did not want to perform the wound care treatments, therefore delegating the treatments to floor nurse. LVN A stated she initially measured Resident #1's wound on [DATE], and at that time it was a small skin tear. (Note: Resident #1's Wound Assessment Report, dated [DATE] reflected an abrasion measuring 1.50 cm in length by 2.00 cm in width on his left buttocks). Resident #1's Nurse's Notes, dated [DATE] and timed at 7:04 PM reflected the dressing to his was wound clean dry and intact. Interview with LVN C on [DATE] at 11:49 AM revealed she completed wound care treatment for [REDACTED]. LVN C stated at that time the wound was not too bad. LVN C explained the wound did not have an odor at that time. LVN C stated she provided the treatment per the physician's orders [REDACTED]. LVN C stated she did not document the measurements or appearance of the wound because that was the treatment nurse's job. LVN C did not describe the wound. Interview with LVN C on [DATE] at 11:46 AM revealed she provided wound care on to Resident #1 in the beginning. LVN C stated when she provided wound care on [DATE] she observed Resident #1's wound was bigger and more spread out. She revealed she continued to follow the physician's orders [REDACTED]. LVN C stated she did not notify anyone the wound appeared to have changed and become larger in size. LVN C stated there was no odor or drainage to the wound when she provided the treatment. She revealed Resident #1 had an elevated temperature with some chest congestion during this time. LVN C stated she contacted the physician who ordered a chest x-ray for possible pneumonia and [MEDICATION NAME] for chest congestion. LVN C stated the x-ray came back negative for pneumonia. She revealed once pneumonia was ruled out she did not look into any other causes on why Resident #1 had an elevated temperature. LVN C stated an elevated temperature was a sign of an infection. LVN C stated in hindsight she should have notified the physician, DON or treatment nurse that Resident #1's wound appeared worse and the resident showed signs of an infection. LVN C stated she was following physician orders [REDACTED]. Interview with LVN E on [DATE] at 2:18 PM revealed when she returned to work on [DATE] she provided the wound treatment to Resident #1 as ordered. LVN E stated at that time she noticed the wound appeared larger in size. Resident #1's Nurse's Notes, dated [DATE] and timed at 9:36 PM written by LVN D reflected the resident had a temperature of 101.1 and Tylenol was administered. The physician was not notified at this time according to nurse's note. Resident #1's Nurse's Notes, dated [DATE] and timed at 5:14AM LVN X reflected a temperature of 97.9. Resident #1's Nurse's Notes, dated [DATE] and timed at 2:16 PM written by LVN C reflected he had a temperature of 99.7 and Tylenol was administered. Resident #1's Nurse's Notes, dated [DATE] and timed at 9:51 PM written by LVN D reflected the NP was in the building and assessed the resident. Orders were given for a chest x-ray, [MEDICATION NAME] 1200 mg (cough suppressant), and [MEDICATION NAME] (a sterile inhalation solution containing a combination of [MEDICATION NAME] and [MEDICATION NAME]. [MEDICATION NAME] and [MEDICATION NAME] are [MEDICATION NAME][MEDICATION NAME] that relax muscles in the airways and increase air flow to the lungs) every 6 hours for 5 days while awake. No evidence that physician or NP was promoted by nurses to assess Resident #1. Interview with LVN D on [DATE] at 3:33 PM revealed she provided care to Resident #1. LVN D stated when she provided wound care treatment to Resident #1 on [DATE] she observed eschar. LVN D stated Resident #1's wound appeared to have gotten worse at which time she notified LVN A and the DON. LVN D stated she remembered Resident #1 receiving a pressure relieving mattress that night. Interview with LVN A on [DATE] at 12:06 AM revealed she measured the wound on [DATE] and the wound measured 7.0 cm by 11.0 cm. (Note: Resident #1's Wound Assessment Report, dated [DATE], revealed a measurement of 1.50 cm in length by 2.00 cm in width.) LVN A stated the wound was unstageable with eschar. LVN A stated the wound was not deep. Resident #1's physician's orders [REDACTED]. The order reflected to start cleansing area to left buttock with normal saline, pat dry, apply sureprep (skin protectant) to peri wound, apply puralol AG (collagen based wound dressing) the cover with dry dressing daily and PRN. Resident #1's Nurse's Notes, dated [DATE] and timed at 2:44 PM by LVN C reflected he had a temperature of 99.9 and Tylenol was administered. The dressing to his sacrum was changed as ordered. The note reflected no measurements or description of the wound. Resident #1's [DATE] TAR reflected an entry dated [DATE] to cleanse the area to left buttock with normal saline, pat dry, apply sureprep to peri wound, apply puralol AG the cover with dry dressing daily and PRN. The treatment was completed on [DATE]. Review of Resident #1's dietician note dated [DATE] at 3:29 PM revealed the resident had a Stage II area. Interview with LVN B on [DATE] at 9:40 AM revealed LVN B stated she became the facility treatment nurse on [DATE] during the transition period between treatment nurses the floor nurses were completing wound care on the residents. LVN B stated LVN A became the MDS Coordinator on [DATE] and during the time period between when she became the treatment nurse on [DATE] the floor nurses were providing wound treatments. Interview with LVN B on [DATE] at 11:30 AM revealed she observed Resident #1's wound on [DATE] at which time new treatment orders were received from the physician which included an antibiotic, Bactrim to treat infection of wound. LVN B stated the wound did not have an odor. The wound had slough in it. Resident #1's Nurse's Notes, dated [DATE] and untimed completed by LVN B reflected, This nurse assess open area to resident's sacrum. Odor noted to area and slough, eschar 8x12 noted to open area, wound bed. No pain, drainage present at this time. No dressing noted due to CNA has provided incontinent care. new order to cleanse are with ns (normal saline), pat dry apply sure prep to peri wound, then apply Santyl to wound bed with moist gauze and cover with [MEDICATION NAME] dressing daily. Dressing completed per orders. Notified DON of wound care and wound area due to appearance. Informed charge nurse to notify MD of odor and obtain labs and possible antibiotic for wound. Charge nurse voiced understanding. Resident #1's Nurse's Note, dated [DATE] at 11:04 AM by LVN C , reflected the resident's temperature was 97.6. Resident #1's Nurse's Note, dated [DATE] and timed at 1:09 PM by LVN D reflected the resident was given initial dose of Bactrim ds from ekit with NARN (no adverse reactions noted) Dressing to sacrum clean dry and intact. Resident #1's physician's orders [REDACTED]. Resident #1's physician's orders [REDACTED]. Start: cleanse area to sacrum with normal saline, pat dry apply sureprep (skin protectant) to peri wound, then apply bandage to wound bed (nickel thick) and moist gauze, cover, [MEDICATION NAME] dressing (non-Adhesive is ideal for partial and shallow full-thickness wounds with drainage) daily and PRN. Resident #1's [DATE] TAR reflected an entry dated [DATE], which was to cleanse the area to his sacrum with normal saline, pat dry, apply sureprep to peri wound, then apply bandage to wound bed (nickel thick) and moist gauze, cover, [MEDICATION NAME] dressing daily and PRN. Treatment completed on [DATE] LVN B. Resident #1's Complete Blood Count laboratory results, dated [DATE], reflected an elevated white blood count of 9.2 on [DATE] to 19.5 on [DATE], which indicated a possible infection. Interview with CNA H on [DATE] at 10:30 AM revealed Resident #1's wound started out as a small skin tear. CNA H stated she observed the same area approximately a week later when assisting the nurse with care at that time the wound was the size of her hand. CNA H stated this occurred because Resident #1's brief had not been changed routinely by the other aides for several days. CNA H stated normally Resident #1 received incontinent care at least 3X per shift. Interview with LVN B on [DATE] at 8:15 AM revealed LVN B explained Resident #1 did have an abrasion to his buttocks. LVN B stated the blister came off of the abrasion and the wound developed into a Stage II pressure ulcer. LVN B stated when it was discovered the abrasion had gotten worse and developed into a pressure ulcer, the treatment orders were changed at that time. LVN B stated Resident #1 was sent out to the hospital at the family ' s request after the family observed Resident #1 had difficulty breathing and the wound appeared too had gotten larger. LVN B stated when she observed the wound on [DATE] the wound had slough in it, the treatment orders were changed again and Resident #1 was placed on an antibiotic. Interview with LVN E on [DATE] at 2:18 PM revealed when she came to work on [DATE] the outgoing nurse reported Resident #1 was having difficulty breathing. LVN E stated she administered a breathing treatment to Resident #1. LVN E stated Resident #1's family was in the room when she administered the breathing treatment and provided wound care. LVN E stated when she provided the treatment; the wound appeared to have gotten worse. LVN E stated the family member commented that the wound was larger in size. LVN E stated the family member stated he/she wanted Resident #1 sent to the hospital for further evaluation due to shortness of breath and wound appeared to have gotten worse. LVN E stated she notified her supervisor of the family's request. LVN E described the wound as having zero odor or drainage. The surrounding tissue as slough and the middle pinkish with zero eschar. LVN E stated when she initially saw the wound it was a skin tear and when she saw it the last time on [DATE] it had developed into a pressure ulcer. LVN E stated she did not recall if Resident #1 had a fever. LVN E stated she had received training in school over wound care and had in-services over wound care. Resident #1's physician's orders [REDACTED]. Review of Resident #1 hospital admission nurse's note dated [DATE] revealed resident was admitted to the hospital on [DATE] due to shortness of breath, abdominal pain and diarrhea. Hospital nurses' note dated [DATE] reflected Resident #1 had a stage II decubitus pressure ulcer to sacrum upon admission. Review of Resident #1 hospital history and physical assessment dated [DATE] revealed Resident #1 was found to have leukocytosis (increased white blood cell count due to infection), [MEDICAL CONDITION](increased heart rate) and [MEDICAL CONDITION] requiring admission to MICU (Medical Intensive Care Unit). [MEDICAL CONDITION] from stage II decubitus ulcer. Review of Resident #1 hospital death pronouncement note dated [DATE] revealed Resident #1 expired on [DATE] at 9:24 PM. Resident found to have [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interview with family member on [DATE] at 9:00 AM revealed family member stated they were notified by the physician at the local hospital that Resident #1 died due to an infection of the wound. Resident #1's Nurse's Note, dated [DATE] completed by LVN B, reflected, This nurse notified by weekend supervisor on [DATE] of resident d/c to ER due to shortness of breath and wound care concerns from family member. Informed weekend supervisor that this nurse notify family member of all wound care orders and lab workup and medication regimen. Family member stated Resident #1 was breathing different and his wound had become bigger and family member was concerned. Family member stated he has been wanting him to go to hospital. Administrator was notified of Immediate Jeopardy on [DATE] at 10:00 AM, Administrator voiced understanding of Immediate Threat and a Plan of Removal was requested at this time. The Plan of Removal was accepted on [DATE] 4:11 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance, due to the facility was still monitoring the effectiveness of the Plan of Removal. PLAN OF REMOVAL: Actions implemented by facility: Assessment: A complete head to toe skin sweep was initiated using body diagram sheets (if pressure noted then a pressure ulcer assessment form was utilized and if non pressure noted then a non-pressure assessment form was utilized) on [DATE] and continued through [DATE] completed by corporate wound care nurse, DON, LVN B, ADON, LVN A on [DATE] and a secondary sweep was completed by corporate nursing staff with an end date [DATE]. This included updated assessments which includes pressure and non-pressure assessments; appropriate documentation such as; treatment orders if indicated, notification of MD/ family, care plans updated. The facility did not have a failure in documentation, due the existence in the medical records of assessment orders and care plans. We are incorporating all of the required skin and wound care documentation in our retraining. The skin and wound care documentation will consist of Braden Scale, care planning for skin risk, weekly head to toe skin checks documentation, pressure and non-pressure ulcer assessments, and how to write telephone orders. Reassessment was done using the skin condition record forms(see attached) of current wounds by certified wound nurse, to include current measurements and staging as well as any required treatment changes was started and completed on [DATE] has not ever provided care to this resident. Findings included issues with 3 residents which are broken out as follows: 1 DTI, 5 Stage II and 2 Arterial. Physicians and families were notified for the 3 residents (Resident #9, #11 and #13) on [DATE] by ADON. Care plans were started on [DATE] and completed on [DATE] by corporate nurses. In-services/Training/Competency Validation: On [DATE] an In-service was initiated and completed for nursing administration by certified wound nurse on the following: Head to Toe assessments; correct staging of wounds; correct measuring of wounds; proper positioning; identifying new skin issues; reporting changes in skin issues; Competency will be tested via skills check off headed by certified wound care nurse. Nursing Administration will also be inserviced on therapeutic support surface protocol that includes bottoming out test to determine setting, posting of setting as well as documentation for monitoring of function and setting. In-service was initiated and completed on [DATE] by Certified Wound Therapist who provides support to facilities and has never provided care to this resident. For all remaining staff including weekend, PRN, on leave, DON and Administrator will monitor to ensure remaining receive in-service/training/competency prior to working on the floor. In-service for nursing on the following topics was started [DATE] and completed [DATE] by DON on the following topics: Head to Toe assessments; correct staging of wounds; correct measuring of wounds; proper positioning; identifying new skin issues; reporting changes in skin issues and documentation of family notification. DON has not provided direct care to this resident. Nursing will also be inserviced on therapeutic support surface protocol that includes bottoming out test to determine setting, posting of setting as well as documentation for monitoring of function and setting. This will be started [DATE] and completed on [DATE] DON and/or RCS. DON and RCS have not provided direct care to this resident. No licensed nurse will be permitted to work their scheduled shift without this in-service. All efforts will be made to capture all staff including weekend staff but no staff will be allowed to work until completed. Competency will be tested via skills check off headed by DON and/or RCS. For all remaining staff including weekend, PRN, on leave, DON and Administrator will monitor to ensure remaining receive in-service/training/competency prior to working on the floor. In-service for certified nursing assistants will be completed by DON and/or RCS on positioning and turning at least Q2 hours and more frequently if indicated per the plan of care. The facility will implement a shower sheet for the CNA's to use to mark any skin concerns that they observe. The sheets will be turned into the charge nurse for further assessment and follow up. The sheets will be immediately turned into the charge nurse. They will also be trained to immediately notify their licensed nurse of any skin concerns that they observe. Once skin concern is identified the charge nurse will immediately complete an assessment of the area, obtain treatment orders and notify his facility IDT team i.e. treatment nurse and DON. In-service will be started on [DATE] and completed on [DATE]. No CNAs, PRN or weekend staff will be allowed to work their scheduled shift until they complete the in-service. For all remaining staff including weekend, PRN, on leave, DON and Administrator will monitor to ensure remaining receive in-service/training/competency prior to working on the floor. Skin and wound training will be incorporated into the licensed nurse orientation effective [DATE] and will be conducted by DON. This will ensure that all new hires are being trained prior to working the floor. Monitoring and compliance will be provided by Administrator. Certified wound nurse will come measure and stage all wounds weekly for four weeks until present treatment nurse, LVN B has been deemed competent in staging and assessment which will include supervised dressing changes and wound assessment with return demonstration and skills validation as identified by peer reviewer. Once a wound is identified by LVN B her process is: After initial assessment, orders and notification per protocol she will monitor during provision of wound care and weekly head to toe skin checks. For the next four weeks she will have a peer reviewer who is certified in wound care to validate staging and assessment of wounds. If a wound gets worse, her steps will be: If a wound is noted to get worse the facility will immediately notify physician and family, as well as implement update treatment plan that may include hospitalization if indicated or if deemed necessary by attending physician. Monitoring: Facility will implement weekly wound rounds by interdisciplinary team [DATE]. The team will be composed of a PT, DON and Treatment Nurse. These rounds will enable nursing administration to have oversight of wound care and ensure that staffing is appropriate and resident wounds are progressing as per plans of care. Weekly head to toe skin checks will be completed weekly by Nursing Administration to include ADON and DON for four weeks then monthly thereafter. Any issues identified will be immediately corrected by nursing administration and/or treatment nurse. Residents noted to acquire pressure ulcers in the facility will have a root cause analysis performed to identify cause or contributing factors, as well as implement preventative solutions by DON. All findings will be reported to the QAPI committee consisting of Administrator, DON, LVN B and ADON. Medical Director Notification and Involvement: DON contacted Medical Director and notified him of the Immediate Jeopardy on [DATE]. Overall Responsibility for Plan of Removal: Administrator will monitor this plan of removal to ensure all tasks will be completed. Review of results of facility skin sweep completed [DATE] revealed facility completed skin assessment on all residents, identifying and assessing all skin issues, ensuring proper treatments and updating care plans to reflect treatment. Review of the In-service Agenda revealed all of the items identified in the Plan of Removal were addressed. In-services included: Distinguishing deep tissue injuries from other skin issues, Identifying bottoming out and setting of the low air loss mattress, head to toe assessment on admission and readmission, staging and measuring wounds, wound documentation, weekly skin assessments/wound reporting, prevention and Management of Pressure Ulcers-Evidence Based Best Practice, shower sheets, reporting skin issues, preventative care for residents at risk for wounds and proficiency checks involved wound assessment and wound care. Following the acceptance of the plan of removal on [DATE], monitoring of in-service documents, attendance rosters, proficiency check lists and interview of staff representing all shifts was completed. Staff members were asked about the in-services they attended, what they learned, what the overall purpose of the in-services was, how it applied to them, did it change their practice? and the impact on the facility. Staff interviewed on various shifts included: LVN F, CNA B, LVN G, LVN C, CNA H, CNA I, CNA J, CNA P, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, LVN B, LVN M, LVN N LVN O. RN K, RA L, DON and the Administrator. All staff were able to articulate the in-service material and expressed varying thoughts on what they took away from the educational opportunities. They all identified a renewed focus on basic care, wound prevention, identification and early reporting. One CNA expressed it well; if you can see it, report it. The Immediate Jeopardy was removed on [DATE] at 4:11 PM; the facility remained out of compliance due to continued monitoring of the effectiveness of the Plan of Removal. Census dated [DATE] reflected a census of 94 residents.

Based on observation, interview and record review, the facility failed to ensure and a resident having pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for one (Residents #1) of 15 residents reviewed for pressure ulcers. 1. Staff failed to properly assess and recognize a change in condition to Resident 1's wound. Resident #1 had skin abrasion on [DATE] that developed into a Stage II pressure ulcer on [DATE]. Resident was sent to the hospital with a change in condition. Resident #1 was treated for [REDACTED]. Resident #1 expired due [MEDICAL CONDITION] infection [DATE]. 2. Staff failed to recognize and intervene when there was significant size increase and possible infection to Resident #1's pressure ulcer. LVN C failed to notify the DON and the Physician when the pressure ulcer deteriorated. 3. Facility failed to identify a change in condition to Resident's #1's wound when the wound began to deteriorate. On [DATE] the wound measured 1.50 cm by 2.0 cm, and on [DATE] the wound measured 8.0 cm by 12.0 cm. Facility's failure to properly assess and recognize deterioration of Resident #1's pressure ulcer resulted in resident being admitted to the hospital with [REDACTED]. Resident expired on [DATE] as a result [MEDICAL CONDITION] to infected pressure ulcer. An Immediate Jeopardy (IJ) was identified on [DATE] at 10:00 AM. While the IJ was removed on [DATE], the facility remained out of compliance, due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect 65 residents, who are identified on the Pressure Ulcer Risk Report as mild to high risk for the development of pressure ulcers by placing them at risk for skin breakdown and development of pressure ulcers, pain and discomfort, which could result in osteo[DIAGNOSES REDACTED] (infection of the bone),[MEDICAL CONDITION] (infection of the blood), untreated skin problems and/or death. Findings included: 1. Review of Resident #1 face sheet reflected resident was an [AGE] year-old-male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's care plan dated [DATE] revealed resident had a [DEVICE], bedfast and required extensive assistance with ADLs. Resident was at risk for pressure ulcers; interventions included daily observation of skin with routine care, full skin evaluation weekly with bath/shower, float heels on pillow, use pillows or other supportive devices to assist with positioning and avoid restrictive clothing; resident was at risk for skin breakdown due to left sided [MEDICAL CONDITION]; interventions included resident was to be provided with pressure reducing surfaces on bed and chair, assistance with position changes and skin was to be kept clean and dry and avoid shearing/friction; [DATE] resident had an abrasion to left buttocks; interventions included treatment was to be followed by physician as ordered, weekly evaluation of wound healing to be completed, daily observation of skin with routine care, full skin evaluation weekly with bath/shower, adjustment of treatment if not healing within ,[DATE] weeks, provide family with progress report of healing status and prompt attention to incontinent episodes. Review of Resident #1 Braden Risk dated [DATE] revealed Resident #1 received a score of 10 which indicated high risk for pressure ulcers. Resident had limited mobility, required maximum assistance, and frequent repositioning. Resident #1 had limited pain perception. Resident #1's Nurse's Notes dated [DATE] and timed at 11:12PM reflected the resident had an open area to his left buttock. The area was cleaned with normal saline, dried and left open to air. The NP was notified. Family notified with no response. Interview with LVN E on [DATE] at 2:18 PM revealed on [DATE] she was called into Resident #1's room by the CNA. LVN E stated Resident #1 had an abrasion/skin tear to his left buttock. LVN E stated she notified the nurse practitioner and left a message for the family and the treatment nurse regarding the abrasion. Review of Resident #1's Wound Assessment Report, dated [DATE] and completed by LVN A, revealed an abrasion measuring 1.50 cm in length by 2.00 cm in width on his left buttocks related to moisture associated damage. There were no signs or symptoms of an infection. (Note: this is the only Wound Assessment Report completed for Resident #1.) Resident #1's undated physician's orders [REDACTED]. Exuderm (is a used to cover the wound) every 3 days and PRN. Resident #1's [DATE] TAR reflected an entry dated [DATE] to clean area to left buttock with Normal saline, pat dry, apply sure prep to peri-wound, apply puracol AG, then cover with Exuderm dressing every 3 days and PRN. The treatment was completed on [DATE], [DATE] and [DATE]. Resident #1 ' s Nurse's Notes dated [DATE] and timed at 12:30 PM reflected an abrasion to his left buttock related to moisture associated damage. Interview with LVN A on [DATE] at 12:06 AM revealed she was the former treatment nurse. LVN A stated LVN B is the new treatment nurse. LVN B stated during the transition period LVN B did not want to perform the wound care treatments, therefore delegating the treatments to floor nurse. LVN A stated she initially measured Resident #1's wound on [DATE], and at that time it was a small skin tear. (Note: Resident #1's Wound Assessment Report, dated [DATE] reflected an abrasion measuring 1.50 cm in length by 2.00 cm in width on his left buttocks). Resident #1's Nurse's Notes, dated [DATE] and timed at 7:04 PM reflected the dressing to his was wound clean dry and intact. Interview with LVN C on [DATE] at 11:49 AM revealed she completed wound care treatment for [REDACTED]. LVN C stated at that time the wound was not too bad. LVN C explained the wound did not have an odor at that time. LVN C stated she provided the treatment per the physician's orders [REDACTED]. LVN C stated she did not document the measurements or appearance of the wound because that was the treatment nurse's job. LVN C did not describe the wound. Interview with LVN C on [DATE] at 11:46 AM revealed she provided wound care on to Resident #1 in the beginning. LVN C stated when she provided wound care on [DATE] she observed Resident #1's wound was bigger and more spread out. She revealed she continued to follow the physician's orders [REDACTED]. LVN C stated she did not notify anyone the wound appeared to have changed and become larger in size. LVN C stated there was no odor or drainage to the wound when she provided the treatment. She revealed Resident #1 had an elevated temperature with some chest congestion during this time. LVN C stated she contacted the physician who ordered a chest x-ray for possible pneumonia and [MEDICATION NAME] for chest congestion. LVN C stated the x-ray came back negative for pneumonia. She revealed once pneumonia was ruled out she did not look into any other causes on why Resident #1 had an elevated temperature. LVN C stated an elevated temperature was a sign of an infection. LVN C stated in hindsight she should have notified the physician, DON or treatment nurse that Resident #1's wound appeared worse and the resident showed signs of an infection. LVN C stated she was following physician orders [REDACTED]. Interview with LVN E on [DATE] at 2:18 PM revealed when she returned to work on [DATE] she provided the wound treatment to Resident #1 as ordered. LVN E stated at that time she noticed the wound appeared larger in size. Resident #1's Nurse's Notes, dated [DATE] and timed at 9:36 PM written by LVN D reflected the resident had a temperature of 101.1 and Tylenol was administered. The physician was not notified at this time according to nurse's note. Resident #1's Nurse's Notes, dated [DATE] and timed at 5:14AM LVN X reflected a temperature of 97.9. Resident #1's Nurse's Notes, dated [DATE] and timed at 2:16 PM written by LVN C reflected he had a temperature of 99.7 and Tylenol was administered. Resident #1's Nurse's Notes, dated [DATE] and timed at 9:51 PM written by LVN D reflected the NP was in the building and assessed the resident. Orders were given for a chest x-ray, [MEDICATION NAME] 1200 mg (cough suppressant), and [MEDICATION NAME] (a sterile inhalation solution containing a combination of [MEDICATION NAME] and [MEDICATION NAME]. [MEDICATION NAME] and [MEDICATION NAME] are [MEDICATION NAME][MEDICATION NAME] that relax muscles in the airways and increase air flow to the lungs) every 6 hours for 5 days while awake. No evidence that physician or NP was promoted by nurses to assess Resident #1. Interview with LVN D on [DATE] at 3:33 PM revealed she provided care to Resident #1. LVN D stated when she provided wound care treatment to Resident #1 on [DATE] she observed eschar. LVN D stated Resident #1's wound appeared to have gotten worse at which time she notified LVN A and the DON. LVN D stated she remembered Resident #1 receiving a pressure relieving mattress that night. Interview with LVN A on [DATE] at 12:06 AM revealed she measured the wound on [DATE] and the wound measured 7.0 cm by 11.0 cm. (Note: Resident #1's Wound Assessment Report, dated [DATE], revealed a measurement of 1.50 cm in length by 2.00 cm in width.) LVN A stated the wound was unstageable with eschar. LVN A stated the wound was not deep. Resident #1's physician's orders [REDACTED]. The order reflected to start cleansing area to left buttock with normal saline, pat dry, apply sureprep (skin protectant) to peri wound, apply puralol AG (collagen based wound dressing) the cover with dry dressing daily and PRN. Resident #1's Nurse's Notes, dated [DATE] and timed at 2:44 PM by LVN C reflected he had a temperature of 99.9 and Tylenol was administered. The dressing to his sacrum was changed as ordered. The note reflected no measurements or description of the wound. Resident #1's [DATE] TAR reflected an entry dated [DATE] to cleanse the area to left buttock with normal saline, pat dry, apply sureprep to peri wound, apply puralol AG the cover with dry dressing daily and PRN. The treatment was completed on [DATE]. Review of Resident #1's dietician note dated [DATE] at 3:29 PM revealed the resident had a Stage II area. Interview with LVN B on [DATE] at 9:40 AM revealed LVN B stated she became the facility treatment nurse on [DATE] during the transition period between treatment nurses the floor nurses were completing wound care on the residents. LVN B stated LVN A became the MDS Coordinator on [DATE] and during the time period between when she became the treatment nurse on [DATE] the floor nurses were providing wound treatments. Interview with LVN B on [DATE] at 11:30 AM revealed she observed Resident #1's wound on [DATE] at which time new treatment orders were received from the physician which included an antibiotic, Bactrim to treat infection of wound. LVN B stated the wound did not have an odor. The wound had slough in it. Resident #1's Nurse's Notes, dated [DATE] and untimed completed by LVN B reflected, This nurse assess open area to resident's sacrum. Odor noted to area and slough, eschar 8x12 noted to open area, wound bed. No pain, drainage present at this time. No dressing noted due to CNA has provided incontinent care. new order to cleanse are with ns (normal saline), pat dry apply sure prep to peri wound, then apply Santyl to wound bed with moist gauze and cover with [MEDICATION NAME] dressing daily. Dressing completed per orders. Notified DON of wound care and wound area due to appearance. Informed charge nurse to notify MD of odor and obtain labs and possible antibiotic for wound. Charge nurse voiced understanding. Resident #1's Nurse's Note, dated [DATE] at 11:04 AM by LVN C , reflected the resident's temperature was 97.6. Resident #1's Nurse's Note, dated [DATE] and timed at 1:09 PM by LVN D reflected the resident was given initial dose of Bactrim ds from ekit with NARN (no adverse reactions noted) Dressing to sacrum clean dry and intact. Resident #1's physician's orders [REDACTED]. Resident #1's physician's orders [REDACTED]. Start: cleanse area to sacrum with normal saline, pat dry apply sureprep (skin protectant) to peri wound, then apply bandage to wound bed (nickel thick) and moist gauze, cover, [MEDICATION NAME] dressing (non-Adhesive is ideal for partial and shallow full-thickness wounds with drainage) daily and PRN. Resident #1's [DATE] TAR reflected an entry dated [DATE], which was to cleanse the area to his sacrum with normal saline, pat dry, apply sureprep to peri wound, then apply bandage to wound bed (nickel thick) and moist gauze, cover, [MEDICATION NAME] dressing daily and PRN. Treatment completed on [DATE] LVN B. Resident #1's Complete Blood Count laboratory results, dated [DATE], reflected an elevated white blood count of 9.2 on [DATE] to 19.5 on [DATE], which indicated a possible infection. Interview with CNA H on [DATE] at 10:30 AM revealed Resident #1's wound started out as a small skin tear. CNA H stated she observed the same area approximately a week later when assisting the nurse with care at that time the wound was the size of her hand. CNA H stated this occurred because Resident #1's brief had not been changed routinely by the other aides for several days. CNA H stated normally Resident #1 received incontinent care at least 3X per shift. Interview with LVN B on [DATE] at 8:15 AM revealed LVN B explained Resident #1 did have an abrasion to his buttocks. LVN B stated the blister came off of the abrasion and the wound developed into a Stage II pressure ulcer. LVN B stated when it was discovered the abrasion had gotten worse and developed into a pressure ulcer, the treatment orders were changed at that time. LVN B stated Resident #1 was sent out to the hospital at the family ' s request after the family observed Resident #1 had difficulty breathing and the wound appeared too had gotten larger. LVN B stated when she observed the wound on [DATE] the wound had slough in it, the treatment orders were changed again and Resident #1 was placed on an antibiotic. Interview with LVN E on [DATE] at 2:18 PM revealed when she came to work on [DATE] the outgoing nurse reported Resident #1 was having difficulty breathing. LVN E stated she administered a breathing treatment to Resident #1. LVN E stated Resident #1's family was in the room when she administered the breathing treatment and provided wound care. LVN E stated when she provided the treatment; the wound appeared to have gotten worse. LVN E stated the family member commented that the wound was larger in size. LVN E stated the family member stated he/she wanted Resident #1 sent to the hospital for further evaluation due to shortness of breath and wound appeared to have gotten worse. LVN E stated she notified her supervisor of the family's request. LVN E described the wound as having zero odor or drainage. The surrounding tissue as slough and the middle pinkish with zero eschar. LVN E stated when she initially saw the wound it was a skin tear and when she saw it the last time on [DATE] it had developed into a pressure ulcer. LVN E stated she did not recall if Resident #1 had a fever. LVN E stated she had received training in school over wound care and had in-services over wound care. Resident #1's physician's orders [REDACTED]. Review of Resident #1 hospital admission nurse's note dated [DATE] revealed resident was admitted to the hospital on [DATE] due to shortness of breath, abdominal pain and diarrhea. Hospital nurses' note dated [DATE] reflected Resident #1 had a stage II decubitus pressure ulcer to sacrum upon admission. Review of Resident #1 hospital history and physical assessment dated [DATE] revealed Resident #1 was found to have leukocytosis (increased white blood cell count due to infection), [MEDICAL CONDITION](increased heart rate) and [MEDICAL CONDITION] requiring admission to MICU (Medical Intensive Care Unit). [MEDICAL CONDITION] from stage II decubitus ulcer. Review of Resident #1 hospital death pronouncement note dated [DATE] revealed Resident #1 expired on [DATE] at 9:24 PM. Resident found to have [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interview with family member on [DATE] at 9:00 AM revealed family member stated they were notified by the physician at the local hospital that Resident #1 died due to an infection of the wound. Resident #1's Nurse's Note, dated [DATE] completed by LVN B, reflected, This nurse notified by weekend supervisor on [DATE] of resident d/c to ER due to shortness of breath and wound care concerns from family member. Informed weekend supervisor that this nurse notify family member of all wound care orders and lab workup and medication regimen. Family member stated Resident #1 was breathing different and his wound had become bigger and family member was concerned. Family member stated he has been wanting him to go to hospital. Review of Pressure Ulcer Prevention Program dated [DATE] revealed if a resident is discovered with skin breakdown or pressure ulcer is identified a licensed nurse will assess the area on a weekly basis to determine progress and modify treatment as appropriate. The resident's physician and family will be notified. The resident's plan of care will be updated. Review of Significant Change and Physician Notification policy (not dated) revealed a resident's family or legal representative and physician are notified when a resident has a significant change in physical, mental or psychosocial status. Examples of significant change include development of pressure sore, elevated temperature, abrupt onset of shortness of breath, abnormal lab results and new wounds or bruises. Administrator was notified of Immediate Jeopardy on [DATE] at 10:00 AM, Administrator voiced understanding of Immediate Threat and a Plan of Removal was requested at this time. The Plan of Removal was accepted on [DATE] 4:11 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance, due to the facility was still monitoring the effectiveness of the Plan of Removal. PLAN OF REMOVAL: Actions implemented by facility: Assessment: A complete head to toe skin sweep was initiated using body diagram sheets (if pressure noted then a pressure ulcer assessment form was utilized and if non pressure noted then a non-pressure assessment form was utilized) on [DATE] and continued through [DATE] completed by corporate wound care nurse, DON, LVN B, ADON, LVN A on [DATE] and a secondary sweep was completed by corporate nursing staff with an end date [DATE]. This included updated assessments which includes pressure and non-pressure assessments; appropriate documentation such as; treatment orders if indicated, notification of MD/ family, care plans updated. The facility did not have a failure in documentation, due the existence in the medical records of assessment orders and care plans. We are incorporating all of the required skin and wound care documentation in our retraining. The skin and wound care documentation will consist of Braden Scale, care planning for skin risk, weekly head to toe skin checks documentation, pressure and non-pressure ulcer assessments, and how to write telephone orders. Reassessment was done using the skin condition record forms(see attached) of current wounds by certified wound nurse, to include current measurements and staging as well as any required treatment changes was started and completed on [DATE] has not ever provided care to this resident. Findings included issues with 3 residents which are broken out as follows: 1 DTI, 5 Stage II and 2 Arterial. Physicians and families were notified for the 3 residents (Resident #9, #11 and #13) on [DATE] by ADON. Care plans were started on [DATE] and completed on [DATE] by corporate nurses. In-services/Training/Competency Validation: On [DATE] an In-service was initiated and completed for nursing administration by certified wound nurse on the following: Head to Toe assessments; correct staging of wounds; correct measuring of wounds; proper positioning; identifying new skin issues; reporting changes in skin issues; Competency will be tested via skills check off headed by certified wound care nurse. Nursing Administration will also be inserviced on therapeutic support surface protocol that includes bottoming out test to determine setting, posting of setting as well as documentation for monitoring of function and setting. In-service was initiated and completed on [DATE] by Certified Wound Therapist who provides support to facilities and has never provided care to this resident. For all remaining staff including weekend, PRN, on leave, DON and Administrator will monitor to ensure remaining receive in-service/training/competency prior to working on the floor. In-service for nursing on the following topics was started [DATE] and completed [DATE] by DON on the following topics: Head to Toe assessments; correct staging of wounds; correct measuring of wounds; proper positioning; identifying new skin issues; reporting changes in skin issues and documentation of family notification. DON has not provided direct care to this resident. Nursing will also be inserviced on therapeutic support surface protocol that includes bottoming out test to determine setting, posting of setting as well as documentation for monitoring of function and setting. This will be started [DATE] and completed on [DATE] DON and/or RCS. DON and RCS have not provided direct care to this resident. No licensed nurse will be permitted to work their scheduled shift without this in-service. All efforts will be made to capture all staff including weekend staff but no staff will be allowed to work until completed. Competency will be tested via skills check off headed by DON and/or RCS. For all remaining staff including weekend, PRN, on leave, DON and Administrator will monitor to ensure remaining receive in-service/training/competency prior to working on the floor. In-service for certified nursing assistants will be completed by DON and/or RCS on positioning and turning at least Q2 hours and more frequently if indicated per the plan of care. The facility will implement a shower sheet for the CNA's to use to mark any skin concerns that they observe. The sheets will be turned into the charge nurse for further assessment and follow up. The sheets will be immediately turned into the charge nurse. They will also be trained to immediately notify their licensed nurse of any skin concerns that they observe. Once skin concern is identified the charge nurse will immediately complete an assessment of the area, obtain treatment orders and notify his facility IDT team i.e. treatment nurse and DON. In-service will be started on [DATE] and completed on [DATE]. No CNAs, PRN or weekend staff will be allowed to work their scheduled shift until they complete the in-service. For all remaining staff including weekend, PRN, on leave, DON and Administrator will monitor to ensure remaining receive in-service/training/competency prior to working on the floor. Skin and wound training will be incorporated into the licensed nurse orientation effective [DATE] and will be conducted by DON. This will ensure that all new hires are being trained prior to working the floor. Monitoring and compliance will be provided by Administrator. Certified wound nurse will come measure and stage all wounds weekly for four weeks until present treatment nurse, LVN B has been deemed competent in staging and assessment which will include supervised dressing changes and wound assessment with return demonstration and skills validation as identified by peer reviewer. Once a wound is identified by LVN B her process is: After initial assessment, orders and notification per protocol she will monitor during provision of wound care and weekly head to toe skin checks. For the next four weeks she will have a peer reviewer who is certified in wound care to validate staging and assessment of wounds. If a wound gets worse, her steps will be: If a wound is noted to get worse the facility will immediately notify physician and family, as well as implement update treatment plan that may include hospitalization if indicated or if deemed necessary by attending physician. Monitoring: Facility will implement weekly wound rounds by interdisciplinary team [DATE]. The team will be composed of a PT, DON and Treatment Nurse. These rounds will enable nursing administration to have oversight of wound care and ensure that staffing is appropriate and resident wounds are progressing as per plans of care. Weekly head to toe skin checks will be completed weekly by Nursing Administration to include ADON and DON for four weeks then monthly thereafter. Any issues identified will be immediately corrected by nursing administration and/or treatment nurse. Residents noted to acquire pressure ulcers in the facility will have a root cause analysis performed to identify cause or contributing factors, as well as implement preventative solutions by DON. All findings will be reported to the QAPI committee consisting of Administrator, DON, LVN B and ADON. Medical Director Notification and Involvement: DON contacted Medical Director and notified him of the Immediate Jeopardy on [DATE]. Overall Responsibility for Plan of Removal: Administrator will monitor this plan of removal to ensure all tasks will be completed. Review of results of facility skin sweep completed [DATE] revealed facility completed skin assessment on all residents, identifying and assessing all skin issues, ensuring proper treatments and updating care plans to reflect treatment. Review of the In-service Agenda revealed all of the items identified in the Plan of Removal were addressed. In-services included: Distinguishing deep tissue injuries from other skin issues, Identifying bottoming out and setting of the low air loss mattress, head to toe assessment on admission and readmission, staging and measuring wounds, wound documentation, weekly skin assessments/wound reporting, prevention and Management of Pressure Ulcers-Evidence Based Best Practice, shower sheets, reporting skin issues, preventative care for residents at risk for wounds and proficiency checks involved wound assessment and wound care. Following the acceptance of the plan of removal on [DATE], monitoring of in-service documents, attendance rosters, proficiency check lists and interview of staff representing all shifts was completed. Staff members were asked about the in-services they attended, what they learned, what the overall purpose of the in-services was, how it applied to them, did it change their practice? and the impact on the facility. Staff interviewed on various shifts included: LVN F, CNA B, LVN G, LVN C, CNA H, CNA I, CNA J, CNA P, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, LVN B, LVN M, LVN N LVN O. RN K, RA L, DON and the Administrator. All staff were able to articulate the in-service material and expressed varying thoughts on what they took away from the educational opportunities. They all identified a renewed focus on basic care, wound prevention, identification and early reporting. One CNA expressed it well; if you can see it, report it. The Immediate Jeopardy was removed on [DATE] at 4:11 PM; the facility remained out of compliance due to continued monitoring of the effectiveness of the Plan of Removal. Census dated [DATE] reflected a census of 94 residents.